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Nonpharmacological Treatments for Patients with Parkinson's Disease
Abstract
Since 2013, a number of studies have enhanced the literature and have guided clinicians on viable treatment interventions outside of pharmacotherapy and surgery. Thirty-three randomized controlled trials and one large observational study on exercise and physiotherapy were published in this period. Four randomized controlled trials focused on dance interventions, eight on treatment of cognition and behavior, two on occupational therapy, and two on speech and language therapy (the latter two specifically addressed dysphagia). Three randomized controlled trials focused on multidisciplinary care models, one study on telemedicine, and four studies on alternative interventions, including music therapy and mindfulness. These studies attest to the marked interest in these therapeutic approaches and the increasing evidence base that places nonpharmacological treatments firmly within the integrated repertoire of treatment options in Parkinson's disease. © 2015 International Parkinson and Movement Disorder Society.
© 2015 Movement Disorder Society.
... PD therapy guidelines comprise pharmacotherapy and deep brain stimulation (DBS) [4,5]. Furthermore, non-pharmacological or non-surgical approaches have attracted increasing interest as part of the therapy regime. ...
... Furthermore, non-pharmacological or non-surgical approaches have attracted increasing interest as part of the therapy regime. They comprise, e.g., physiotherapy, physical activity, occupational therapy, speech therapy, and cognitive and behavioral approaches [4]. Evidence for the efficacy of these interventions is growing [4][5][6][7][8][9][10]. ...
... They comprise, e.g., physiotherapy, physical activity, occupational therapy, speech therapy, and cognitive and behavioral approaches [4]. Evidence for the efficacy of these interventions is growing [4][5][6][7][8][9][10]. ...
Background: Interest in non-pharmacological/non-surgical interventions to treat Parkinson’s disease (PD) has substantially increased. Although a few health-economic studies have been conducted, summary information on the cost-effectiveness is still scarce. Objective: To give an overview of cost-effectiveness analyses (CEA) focusing on non-pharmacological/non-surgical interventions in PD patients. Methods: A systematic literature search was conducted in five databases. Studies were included that provided cost-effectiveness analysis (CEA) or cost-utility analysis (CUA) of non-pharmacological/non-surgical interventions in PD patients. Study quality was assessed with the Drummond and CHEERS 2022 checklists respectively, for economic evaluation. Results: N = 9 studies published between 2012–2023 were identified. Most studies undertook a CUA (n = 5); n = 3 reported a combination of CEA and CUA, and n = 1 a pure CEA. Most studies (n = 6) examined physical exercise. The CEA studies identified additional costs of 170€ –660€ for the improvement of one single unit of a clinical outcome and savings of 18.40€ –22.80€ per score gained as measured with established instruments. The four studies that found significant quality of life benefits show large variations in the incremental cost effectiveness ratio (ICER) of 3,220€ –214,226€ per quality-adjusted life year (QALY); notably interventions were heterogenous regarding content and intensity. Conclusions: Despite increasing numbers of non-pharmacological/non-surgical intervention trials in PD patients, health-economic evaluations are rare. The examined intervention types and health-economic results vary greatly. Together with the heterogeneity of the health-economic studies these factors limit the conclusions that can be drawn. Further research and a standardization of methods is needed to allow decision makers to make meaningful interpretations, and to allocate scarce resources.
... This surge is combined with limited treatment options, constitutes an enormous challenge in the management of patients and heightens the burden on caregivers [3], and this is greatly magnified in low-to-middle-income countries. Therefore, managing PD necessitates a holistic multidisciplinary approach that extends beyond pharmacotherapy to encompass a range of allied health therapies, including cultural understanding between patient and caregiver [4]. ...
... The trio of physiotherapy (PT), occupational therapy (OT), and speech-language therapy (SLT) is essential for tackling the diverse and intricate symptoms presented by PD [4]. Nutritionists, PD nurse specialists, social workers, and recreational therapists play an essential role and are valuable members of the allied health team. ...
... Speech and language therapy assists with speech and swallowing difficulties commonly seen in PD [1,4]. Dysarthria and dysphagia often show limited improvement with pharmacotherapy but may benefit from specialized SLT interventions, including focused training on voice and swallowing [4]. ...
Allied health therapies refer to a range of healthcare professionals, including physiotherapists, occupational and speech-language therapists, who aim to optimize daily function and quality of life in conjunction with medical care. In this narrative review of literature on allied health therapies in people with Parkinson’s disease (PD), we focused on the diversity in healthcare access, state of the art, current challenges in the African continent, and proposed solutions and future perspectives. Despite the increasing prevalence and awareness of PD in Africa, numerous challenges persist in its management. These include resource limitations, geographical barriers, sociocultural beliefs, and economic constraints. Nevertheless, innovative solutions, including telerehabilitation and community-based rehabilitation, offer hope. Collaborative efforts within the continent and internationally have shown potential in bridging training and resource gaps. Significant strides can be made with tailored interventions, technological advancements, and multifaceted collaborations. This review offers practical insights for healthcare professionals, policymakers, and caregivers to navigate and optimize PD care in the African context.
... There was a 15-year limit set on the publication dates. This date range is consistent with Bloem et al. (2015) who, in their review, identified the increase in high-quality non-pharmacological trial publications as of 2013 [20]. In our literature search, we observed a similar inflection in the search results with no eligible studies identified between 2008 and 2012 followed by an increase in those meeting our criteria, suggesting that this date range captured relevant data to address our research questions. ...
... There was a 15-year limit set on the publication dates. This date range is consistent with Bloem et al. (2015) who, in their review, identified the increase in high-quality non-pharmacological trial publications as of 2013 [20]. In our literature search, we observed a similar inflection in the search results with no eligible studies identified between 2008 and 2012 followed by an increase in those meeting our criteria, suggesting that this date range captured relevant data to address our research questions. ...
Background: Low adherence to non-pharmacological interventions can impact treatment effectiveness. Yet, there is limited information on adherence barriers and facilitators to non-pharmacological interventions in Parkinson’s disease (PD). Objective: 1) To examine the quality of adherence reporting and 2) to identify key determinants of adherence to PD non-pharmacological interventions. Methods: A rapid evidence assessment was conducted, following PRISMA guidelines, that included controlled studies of exercise, physiotherapy, occupational therapy, speech-language therapy with explicit reporting of ‘adherence’ OR ‘compliance’, published in the last 15 years. Data extracted included: adherence rates, adherence outcomes, and factors associated with adherence. A collaborative thematic analysis was conducted to identify determinants of adherence. Results: The search yielded 2,445 articles of which 114 met criteria for full screening with 45 studies meeting all inclusion criteria. High quality adherence data that aligned with the intervention goals were reported by 22.22%(N = 10) of studies, with the majority reporting attendance/attrition rates only 51.11%(N = 23). Four major themes (34 subthemes) emerged: disease and health, personal, program design, and system and environmental. Conclusions: There has been limited progress in the quality of adherence reporting in PD non-pharmacological interventions over the last decade. Acknowledging this limitation, key determinants of adherence included: alignment with personal beliefs, attitudes, and expectations; the demands of the intervention and worsening disease symptoms and personal/time obligations; and accessibility and safety concerns. Program design elements found to facilitate adherence included: opportunities for social engagement and in-person offerings linked to higher levels of interventionist support, performative feedback, and social reinforcement.
... Motor-cognitive interactive rehabilitation has proven to have an impact on neural pathways related to cognitive and motor functions. Attention and executive functions are a set of top-down processes that modulate goal-based movements (Calleo et al., 2012;Bloem et al., 2015). The integration of cognitive training and motor exercise would enhance PD patients' ability to plan and execute movements while activating brain regions related to memory, attention, and problemsolving (Maidan et al., 2017;King et al., 2020;Johansson et al., 2022). ...
... The increased FC was significantly correlated with improved balance ability. The intervention has also been regarded as a complementary option for PD management (Frazzitta et al., 2011;Bloem et al., 2015). However, in contrast with previous studies that revealed that physical exercise has a positive effect on cognitive function by influencing activation and metabolism of the frontal lobe circuit, there were no significant changes in the motor-cognitive pathway in the TPT group. ...
IntroductionMotor-cognitive interactive interventions, such as action observation training (AOT), have shown great potential in restoring cognitive function and motor behaviors. It is expected that an advanced AOT incorporating specific Tai Chi movements with continuous and spiral characteristics can facilitate the shift from automatic to intentional actions and thus enhance motor control ability for early-stage PD. Nonetheless, the underlying neural mechanisms remain unclear. The study aimed to investigate changes in brain functional connectivity (FC) and clinical improvement after 12 weeks of Tai Chi-based action observation training (TC-AOT) compared to traditional physical therapy (TPT).Methods
Thirty early-stage PD patients were recruited and randomly assigned to the TC-AOT group (N = 15) or TPT group (N = 15). All participants underwent resting-state functional magnetic resonance imaging (rs-fMRI) scans before and after 12 weeks of training and clinical assessments. The FCs were evaluated by seed-based correlation analysis based on the default mode network (DMN). The rehabilitation effects of the two training methods were compared while the correlations between significant FC changes and clinical improvement were investigated.ResultsThe results showed that the TC-AOT group exhibited significantly increased FCs between the dorsal medial prefrontal cortex and cerebellum crus I, between the posterior inferior parietal lobe and supramarginal gyrus, and between the temporal parietal junction and clusters of middle occipital gyrus and superior temporal. Moreover, these FC changes had a positive relationship with patients’ improved motor and cognitive performance.DiscussionThe finding supported that the TC-AOT promotes early-stage PD rehabilitation outcomes by promoting brain neuroplasticity where the FCs involved in the integration of sensorimotor processing and motor learning were strengthened.
... A fundamental aspect in the sustaining of teams is interprofessional education that increases knowledge, promotes team coherence and changes practice in the care of PD (Cohen et al. 2016). While key stakeholders are a PD nurse specialist and a neurologist, to mention only the health care specialists, up to 20 different professionals may ally to constitute an interdisciplinary team supporting PwP and their families (Giladi et al. 2014;Bloem et al. 2015;Qamar et al. 2017;Radder et al. 2020). ...
... These include involvement of psychologists, neuropsychologists, speech and language therapist, physiotherapists, psychiatrists, nutritional advisors, social service, and occupational therapists. Progression of the disease and evaluation of advanced therapies often calls for the involvement of gastroenterologists, neuroradiologists and neurosurgeons, neuro-ophthalmologist, urologists, sleep specialists, dentists, geriatricians specialized in PD, palliative care, and other professionals that are crucial for a patient's recovery and their effective management (Bloem et al. 2015;Badger et al. 2018;Krause et al. 2022;Parashos et al. 2020;Rajan et al. 2020;van Munster et al. 2021). All health care professionals have a shared role in providing person-centered care for older people. ...
Managing the many issues in advanced Parkinson’s disease (PD) requires education, continuous support, and specialized outpatient care involving a variety of allied healthcare professionals. It would be greatly appreciated if general neurologists and professionals from various disciplines who work with people diagnosed with Parkinson’s disease (PwP) could remain knowledgeable about the existing therapies and their respective roles within the treatment continuum. The movement disorders specialist and the PD nurse are key actors in the coordination of a targeted and patient-empowering multidisciplinary approach for advanced PD. Affordable and timely access to these therapies for the PwP who may need them is presently a challenge for health systems. Education, training, and support for all the involved stakeholders in the process of PD care may improve quality of life both for PwP and caregivers, and reduce inadequate, expensive, time-consuming, and unsuccessful prolongation of standard medical therapies.
... Parkinson's disease (PD) is a progressive neurodegenerative disease that is characterized by various motor and non-motor manifestations. 1 Because of these manifestations, persons with PD (PwPs) are at increased risk for complications, such as orthopedic injuries and pneumonia. 2 Pharmacological and neurosurgical treatments have limited effects on the prevention of certain complications, such as orthopedic injuries or pneumonia, because they only marginally relieve symptoms related to these complications, such as balance and swallowing deficits. Therefore, there is a need for complementary treatments that are applicable to a broad spectrum of PwPs. ...
... Specialized PT professionals using interventions such as treadmill training, stationary bicycle training, or multimodal exercise can decrease the risk of PD-related complications. 2,[16][17][18] Recent work showed that PT delivered by specialized therapists led to fewer PD-related complications and lower costs than PT delivered by generic therapists. 3 These good outcomes were reached by the specialized therapists with fewer treatment sessions. ...
Background:
Specialized versus generic physiotherapy (PT) reduces Parkinson's disease (PD)-related complications. It is unclear (1) whether other specialized allied heath disciplines, including occupational therapy (OT) and speech and language therapy (S<), also reduce complications; (2) whether there is a synergistic effect among multiple specialized disciplines; and (3) whether each allied health discipline prevents specific complications.
Objectives:
To longitudinally assessed whether the level of expertise (specialized vs. generic training) of PT, OT, and S< was associated with the incidence rate of PD-related complications.
Methods:
We used claims data of all insured persons with PD in the Netherlands between January 1, 2010, and December 31, 2018. ParkinsonNet-trained therapists were classified as specialized, and other therapists as generic. We used mixed-effects Poisson regression models to estimate rate ratios adjusting for sociodemographic and clinical characteristics.
Results:
The population of 51,464 persons with PD (mean age, 72.4 years; standard deviation 9.8) sustained 10,525 PD-related complications during follow-up (median 3.3 years). Specialized PT was associated with fewer complications (incidence rate ratio [IRR] of specialized versus generic = 0.79; 95% confidence interval, [0.74-0.83]; P < 0.0001), as was specialized OT (IRR = 0.88 [0.77-0.99]; P = 0.03). We found a trend of an association between specialized S< and a lower rate of PD-related complications (IRR = 0.88 [0.74-1.04]; P = 0.18). The inverse association of specialized OT persisted in the stratum, which also received specialized PT (IRR = 0.62 [0.42-0.90]; P = 0.001). The strongest inverse association of PT was seen with orthopedic injuries (IRR = 0.78 [0.73-0.82]; P < 0.0001) and of S< with pneumonia (IRR = 0.70 [0.53-0.93]; P = 0.03).
Conclusions:
These findings support a wider introduction of specialized allied health therapy expertise in PD care and conceivably for other medical conditions. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
... Multidisciplinary care modalities have been linked to better outcomes in Parkinson's disease (PD) care [1,2]. Patients with PD are at a high risk of inpatient admissions, and 58% of admissions are associated with the complications of this disease [3]. ...
Background: This is a retrospective longitudinal study comparing 374 patients with Parkinson’s disease (PD) who were treated in centers offering a specialized program of enhanced rehabilitation therapy in addition to expert outpatient care to 387 patients with PD, who only received expert outpatient care at movement disorders centers in Italy. Methods: The data are from subjects recruited in the Parkinson’s Outcome Project (POP) at six Italian centers that are part of a multicenter collaboration for care quality improvement (the Fresco Network). The effects were measured with a baseline and a follow-up clinical evaluation of the Timed-Up-and-Go test (TUG), Parkinson’s Disease Questionnaire (PDQ-39), and Multidimensional Caregiver Strain Index (MCSI), the number of falls and hospitalizations for any cause. We used a generalized linear mixed model with the dependent variables being the response variable, which included the covariates demographics, evaluation, and treatment variables. Results: We found that the subjects who underwent specialized enhanced rehabilitation had a better motor outcome over time than those who were managed by expert neurologists but had participated in community programs for exercise and other allied health interventions. The greatest effects were seen in patients in the early stages of the disease with a high amount of vigorous exercise per week in the last six months. Similar effects were seen for PDQ39, MCSI, the number of falls, and hospitalization. Conclusions: Long-term benefits to motor function and the quality of life in patients with PD and burden reduction in their caregivers can be achieved through a systematic program of specialized enhanced rehabilitation interventions.
... In other words, it is caused by decreased dopamine production, a neurotransmitter in the brain. Postural instability, resting tremor, bradykinesia, muscular rigidity, freezing, and gait impairment are some of the most prominent signs of Parkinson's disease (Bloem et al., 2015). However, damage to cognitive functioning is also present (Wirdefeldt et al., 2011). ...
... The efficacy of pharmacologic treatments decreases over time, and adverse effects become apparent and other treatments' therapeutic effect is limited to some extent. The treatment of FOG is difficult, and despite the optimal pharmacologic and nonpharmacologic interventions are used, the majority of patients will still develop FOG (Bloem et al., 2015). ...
Background
Freezing of gait (FOG) is one of the most disabling gait disturbances in Parkinson’s disease (PD), affecting mobility and balance severely, thereby leading to an increased risk of falls.
Objectives
The purpose of this systematic review and meta-analysis was to investigate the effects of transcranial magnetic stimulation on FOG in PD.
Methods
Based on PRISMA guidelines, we searched the databases of MEDLINE (PubMed), Cochrane Library, PEDro, Embase, and Web of Science. Studies of the English language published up to July 2023 were searched. We retrieved for studies of randomized controlled trials (RCTs) of transcranial magnetic stimulation to treat FOG after PD and screened by inclusion and exclusion criteria. Risk of bias was assessed using the Cochrane Collaboration’s tool (Revman5.30). Characteristics of RCTs were extracted. The heterogeneity of the trials was measured by I² statistic. The effect size was expressed by a standardized mean difference (SMD) with a 95% confidence interval (CI).
Results
A total of 488 articles were screened, after screening sixteen RCTs involved in 408 patients were included in the qualitative analysis, and 15 RCTs were included in meta-analysis. The outcome measures included FOG-Q, walking time, TUG, and UPDRS. Six studies used FOG-Q as outcome measure, six studies used walking time, four studies used TUG, and six studies used UPDRS. Compared with placebo treatment, transcranial magnetic stimulation has positive significant effects in improving gait status with increased walking speed (SMD = −0.41, 95% CI = −0.75 to −0.06, I² = 7% p = 0.02), FOG-Q scores (SMD = −0.55, 95% CI = −0.89 to −0.21, I² = 29%, p = 0.002), UPDRS scores (SMD = −1.08, 95% CI = −1.39 to −0.78, I² = 49%, P < 0.001) and the time of TUG (SMD = −0.56, 95% CI = −0.88 to −0.23, I² = 25%, p = 0.02) decreased.
Conclusion
Transcranial magnetic stimulation could significantly improving gait conditions in PD patients with FOG.
Systematic review registration
https://www.crd.york.ac.uk/PROSPERO/#recordDetails, CRD42023434286.
... Recent management guidelines such as those from the UK National Institute for Health and Clinical Excellence (NICE) [44] and the European Physiotherapy Guidelines for Parkinson's Disease [45] have supported physiotherapy in PD care. Physiotherapy has been found to help maximize functional ability and reduce secondary complications through movement [46]. Despite this, referral rates have been historically low due to a poor knowledge of improved outcomes and poor availability of physiotherapy services [47]. ...
Background: Incidence of disability secondary to Parkinson’s disease is increasing faster globally than any other neurological condition. The diverse appearance of symptomatology associated with Parkinson’s, and the degenerative nature and subsequent functional decline, often increase dependence on caregivers for assistance with daily living, most commonly within a care home setting. Yet, primary literature and evidence synthesis surrounding these unique and complex care needs, challenges and the lived experiences of this population living in long-term nursing or residential facilities remains sparce. The aim of this review is to synthesize qualitative literature about the lived experience of people with Parkinson’s disease living in care home settings. Methods: A systematic search of the literature was conducted in October 2023 across six different databases (CINAHL, Medline, EMBASE, PsycINFO, Scopus and Cochrane Library). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used to guide this review. Results: Five articles met the inclusion criteria. Four themes were identified following evidence synthesis: (1) Unique pharmacological challenges. (2) Transitioning and adapting to care home life and routines. (3) Dignified care within care homes. (4) Multidisciplinary care vacuum in care homes. Conclusion: This review revealed the significant and unique challenges for people with Parkinson’s disease when transitioning into care homes. These are exacerbated by wider social care challenges such as staffing levels, skill mixes and attitudes as well as a lack of disease-specific knowledge surrounding symptomatology and pharmacology. The lack of multi-disciplinary working and risk-adverse practice inhibited person-centred care and autonomy and reduced the quality of life of people living with Parkinson’s disease in care homes. Recommendations for practice highlight training gaps, the need for consistent and improved interdisciplinary working and better person-centred assessment and care delivery.
... Parkinson's disease (PD) is a neurodegenerative disorder characterized by the loss of dopaminergic neurons in the substantia nigra (SN) 1 . A growing literature has demonstrated the benefits of exercise programs for controlling motor symptoms of PD [2][3][4][5] . The reported benefits vary according to the type, intensity, and duration of the exercise. ...
Parkinson’s disease (PD) is characterized by a progressive loss of dopaminergic neurons. Exercise has been reported to slow the clinical progression of PD. We evaluated the dopaminergic system of patients with mild and early PD before and after a six-month program of intense exercise. Using ¹⁸ F-FE-PE2I PET imaging, we measured dopamine transporter (DAT) availability in the striatum and substantia nigra. Using NM-MRI, we evaluated the neuromelanin content in the substantia nigra. Exercise reversed the expected decrease in DAT availability into a significant increase in both the substantia nigra and putamen. Exercise also reversed the expected decrease in neuromelanin concentration in the substantia nigra into a significant increase. These findings suggest improved functionality in the remaining dopaminergic neurons after exercise. Further research is needed to validate our findings and to pinpoint the source of any true neuromodulatory and neuroprotective effects of exercise in PD in large clinical trials.
... Several potentially disease modifying drugs have been studied, but none of these have thus far been shown to alter the progressive course of the disease [2][3][4]. In the absence of disease modifying pharmacological approaches, increasing attention is being paid to non-pharmacological management of the disease [5]. Most work has so far focused on exercise, which can have positive effects on a wide range of symptoms such as gait, balance, and mood [6,7]. ...
Several dietary patterns and nutritional supplements have been linked to the development, progression, and symptomatic treatment of Parkinson’s disease (PD). Most of the evidence, at this point, is preliminary and based largely on observational studies. Interventional studies are scarce, so the evidence on effectiveness remains inconclusive. Dietary interventions could, analogous to exercise, potentially have a beneficial effect on disease symptoms as well as on the progression of the disease and should therefore be researched in high quality studies. Further work is also needed to study whether dietary interventions, when applied to an at-risk population, have any potential to postpone the onset of manifest PD. In this paper, we summarize all ongoing clinical trials on dietary interventions in PD. We found 10 ongoing studies, all aimed at a different intervention. These studies are mostly exploratory in nature or represent phase I or phase II trials focusing on safety, biological responses, and symptomatic effects. Taken together, we conclude that research on dietary interventions in persons with PD is still in its early days. The results of the various ongoing trials are expected to generate new hypotheses and will help to shape the agenda for future research on this important topic.
... In PD, non-pharmacological treatment approaches focus on everyday life functioning (e.g., gait, falls, activities of daily living, speech) and their underlying impaired body functions (e.g., balance, dexterity). Therefore, utilization of multidisciplinary rehabilitative treatments, which should include physical therapy, occupational therapy, speech and language pathology and psychology, is recommended [13,14]. Several systematic reviews and meta-analyses published in recent years concluded that rehabilitative treatments such as physical therapy have significant effects on motor symptoms and function, including balance, gait, risk of falls, and freezing of gait [15][16][17]. ...
Background
Current evidence on chronic conditions favors promotion of health behaviors as a mean to positively impact health outcomes. In Parkinson’s disease, performing health behaviors is indicated as a means to fight the long-lasting burden of the disease. Understanding actual engagement in health behaviors and patient activation and their association to function and health-related quality of life is therefore important. Our objectives were, among people with Parkinson’s disease: (1) to characterize health behaviors including utilization of rehabilitative treatments, physical activity, and patient activation levels, and (2) to test the associations between these health behaviors and health outcomes.
Methods
A cross-sectional study of 88 people with Parkinson’s disease (age 66.84 ± 8.8) was conducted. Participants answered questionnaires measuring health behaviors including utilization of health professions treatments, physical activity, patient activation, and health outcomes consisting of function and health-related quality of life. Linear regression models were conducted to test associations between measured health behaviors, function and health-related quality of life.
Results
Participants rarely engage in rehabilitative treatments, but showed high levels of patient activation. Controlled by demographics and disease severity, physical activity and patient activation were associated with function (b = 0.41, p < .001; b = 0.2, p = .02, respectively) and physical activity but not patient activation, which was associated with health-related quality of life (b = 0.19, p = .03). There was also interaction effects of physical activity and non-motor symptoms, and physical activity and motor symptoms on health-related quality of life (b = 0.19, p = .02 and b = − 0.22, p = .01, respectively).
Conclusions
In respect to their potential health-related benefits for people with Parkinson’s disease, health professionals’ treatments are underutilized. Findings supported the importance of health behaviors for maintaining function and health-related quality of life among people with Parkinson’s disease. They also show a differential contribution of motor and non-motor symptoms to the association between physical activity and quality of life. It is suggested that policy makers encourage opportunities for physical activity tailored for people with Parkinson’s disease and adopt a proactive stance towards enhancing awareness and use of rehabilitation services.
Trial registration NCT05211700, ClinicalTrials.gov ID: NCT05211700 first release 12/30/2021, https://classic.clinicaltrials.gov/ct2/show/NCT05211700
... We aim to study the effect of HUTS on clinical outcomes to power a future phase III RCT. We expect a large effect of the intervention on the main study parameters, meaning that 50 participants will be sufficient for this RCT [38]. ...
Background
In persons with Parkinson’s Disease (PD) or certain forms of atypical parkinsonism, orthostatic hypotension is common and disabling, yet often underrecognized and undertreated. About half of affected individuals also exhibit supine hypertension. This common co-occurrence of both orthostatic hypotension and supine hypertension complicates pharmacological treatments as the treatment of the one can aggravate the other. Whole-body head-up tilt sleeping (HUTS) is the only known intervention that may improve both. Evidence on its effectiveness and tolerability is, however, lacking, and little is known about the implementability.
Methods
In this double-blind multicenter randomized controlled trial (phase II) we will test the efficacy and tolerability of HUTS at different angles in 50 people with PD or parkinsonism who have both symptomatic orthostatic hypotension and supine hypertension. All participants start with one week of horizontal sleeping and subsequently sleep at three different angles, each maintained for two weeks. The exact intervention will vary between the randomly allocated groups. Specifically, the intervention group will consecutively sleep at 6°, 12° and 18°, while the delayed treatment group starts with a placebo angle (1°), followed by 6° and 12°. We will evaluate tolerability using questionnaires and compliance to the study protocol. The primary endpoint is the change in average overnight blood pressure measured by a 24-hour ambulatory blood pressure recording. Secondary outcomes include orthostatic blood pressure, orthostatic tolerance, supine blood pressure, nocturia and various other motor and non-motor tests and questionnaires.
Discussion
We hypothesize that HUTS can simultaneously alleviate orthostatic hypotension and supine hypertension, and that higher angles of HUTS are more effective but less tolerable. The Heads-Up trial will help to clarify the effectiveness, tolerability, and feasibility of this intervention at home and can guide at-home implementation.
Trial registration
ClinicalTrials.gov NCT05551377; Date of registration: September 22, 2022.
... Section-i comprised demographic information, section-ii included assessment methods, section-iii incorporated treatment protocols for Pd, while section-iV included questions on the PTs' knowledge of VR and Mi. The questions pertaining to assessment methods [33,34] and treatment methods were based on previous studies and clinical guidelines [19,35,36]. The questions on the knowledge assessed specifically knowledge about the use of innovative technologies. ...
Introduction
Patients with Parkinson’s disease are often prescribed physical therapy. Physiotherapists often assist Parkinson’s disease patients with assessment and treatment, but little is known about the assessment tools and interventions they use. Additionally, physical therapists do not consistently integrate standard outcome measures and treatment procedures into their practices. Consequently, this study was carried out to determine physical therapists’ preferences for assessment and treatment of Parkinson’s disease.
Methods
Five hundred questionnaires were distributed to physiotherapists working in clinical settings. Overall, 446 physiotherapists responded to the survey and returned the questionnaires. Questionnaires with incomplete information were excluded from the survey. In total, 418 physiotherapists participated in the study, of whom 324 saw PD patients in their clinical practice.
Results
Overall, 446 physiotherapists responded to the survey and returned the questionnaires. Questionnaires with incomplete information were excluded from the survey. In total, 418 physiotherapists participated in the study, of whom 324 saw PD patients in their clinical practice. Study participants included 43.8% male PTs and 56.2% female PTs with an average age of 30.02 ± 5.38 years. The Berg balance scale for balance assessment was preferred by 220 (67.9%), the Mini Mental State Examination for cognitive assessment was preferred by 317 (97.8%), and the Unified Parkinson’s Disease Rating Scale was preferred by 168 (51.85%) PTs. Neurological PTs employed PNF (proprioceptive neuromuscular facilitation) to decrease stiffness, and exercise and task-focused training for functional training. Virtual Reality and Motor Imagery were also known by 56.6% and 62.4% of PTs, respectively, although only 4.8% and 1.85% used them.
Conclusions
Study results revealed that most physiotherapists follow routine assessment and treatment protocols and do not implement innovative technology in the physical rehabilitation of patients with Parkinson’s disease.
... Although some symptoms, such as motor dysfunction and depression, can be effectively managed with pharmacological interventions or deep brain stimulation, 2,3 other symptoms showed limited or no response to these interventions. 4,5 Furthermore, the effectiveness of medications tends to decrease over time as the disease progresses. 6 As a crucial aspect of neurorehabilitation for Parkinson disease, exercise therapy plays a significant role in the management of motor dysfunction. ...
Objective
The purpose of this review was to investigate the efficacy of rhythmically cued exercise interventions on motor function, cognition, and mental state in patients with Parkinson disease.
Methods
PubMed, Cochrane Database, Web of Science, Embase, and CINAHL were searched June 15, 2023. Original studies investigating the efficacy of rhythmically cued exercise interventions on functions in patients with Parkinson disease were included. The Cochrane risk-of-bias assessment tool was used to evaluate the risk of bias. The protocol was registered in PROSPERO (CRD42022371203).
Results
A total of 38 original studies involving 1486 participants were included. Rhythmically cued exercise interventions demonstrated superior effects on motor function compared to exercise therapy without rhythm (standardized mean difference [SMD] = −0.31). However, no significant improvements were observed in cognition and mental state. Overall, significant improvements were observed in motor examination (SMD = −0.61), Timed “Up & Go” Test (mean difference [MD] = −0.91), activities of daily living (SMD = −0.49), balance (SMD = 0.59), walking velocity (MD = 0.06), step length (MD = 2.65), and stride length (MD = 0.04) following rhythmically cued exercise interventions. No significant improvements were observed in freezing of gait and cadence. Assessment of publication bias showed no significant evidence of publication bias. Meta–regression analyses revealed a significant association between treatment duration and improvement in motor function. Furthermore, adverse events and dropout rates did not significantly differ between the 2 groups.
Conclusions
Rhythmically cued exercise interventions are effective in improving motor function in the early to middle stages of Parkinson disease. More than 10 weeks of intervention yielded better results. However, these interventions do not have a significant impact on cognition and mental states. Importantly, rhythmically cued exercise interventions are safe and well tolerated. Large-scale trials are needed for further confirmation.
Impact
This study contributes to the development of safe and reliable home rehabilitation programs, aiming to enhance the quality of life for patients with Parkinson disease.
... Non-pharmacological treatments have received increased attention in recent years. In non-pharmacological therapy, exercise is an important auxiliary method for treating PD [15]. PD is a chronic progressive disease, and regular exercise can alleviate the skeletal muscle and cardiovascular problems that PD patients develop due to reduced physical activity [16,17]. ...
Objective
The effects of different exercise doses on motor function, balance, mobility, and quality of life (QOL) in patients with Parkinson's disease (PD) were evaluated.
Method
The exercise intervention dose was evaluated based on the recommendations of the American College of Sports Medicine (ACSM) for developing and maintaining cardiorespiratory health, muscle strength, and physical function for PD patients and classified into high ACSM compliance and low or uncertain ACSM compliance. The impact of ACSM compliance on Unified Parkinson's Disease Rating Scale, Part III (UPDRS-III), Berg Balance Scale (BBS), Timed Up and Go (TUG), and 39-item Parkinson's Disease Questionnaire (PDQ-39) in patients with PD was compared using the standardized mean difference (SMD) along with the corresponding 95% confidence interval (95% CI).
Results
A total of 26 articles were included, comprising 32 studies. Twenty-one studies were classified as high ACSM compliance, and 11 studies were classified as low or uncertain ACSM compliance. For the four outcome measures, the SMD ratio of exercise interventions with high ACSM compliance to those with low or uncertain ACSM compliance was as follows: UPDRS-III (− 0.74: − 0.17), TUG (− 0.62: − 0.17), PDQ-39 (− 0.58: − 0.31), and BBS (0.51: 0.52).
Conclusion
The results suggest that compared with exercise interventions with low or uncertain ACSM compliance, exercise interventions with high ACSM compliance had a more significant improvement effect on motor function, mobility, and QOL in PD patients. However, the effect on balance was not as pronounced, and further research is needed to validate these findings.
... These limitations have resulted in the advocation of non-pharmacological and complimentary strategies to be incorporated into management of PD [27], such as participation in regular exercise and dual tasking. Exercise is one of the most well studied non-pharmacological strategies in the management of PD [28]. Rodent studies utilising neurotoxins to induce parkinsonism have provided evidence for the neuroprotective benefits of exercise and its role in mitigating PD progression [26,29,30]. ...
Introduction:
Whilst non-motor experiences of daily living (NMeDL) reduce quality of life (QoL) in people with Parkinson's Disease (PD), research dedicated to NMeDL is lacking compared to motor symptoms. The aim of this Network Meta-Analysis (NMA) was to compare and determine the effects of exercise and dual-task training interventions on NMeDL for people with early-to-mid stage PD.
Methods:
Eight electronic databases were systematically searched, identifying randomised control trials (RCTs) that assessed the effect of interventions on the Movement Disease Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS); Part I scores. A fixed-effect pairwise and NMA were completed and confidence in estimates were assessed using the Confidence in Network Meta-Analysis (CINeMA) framework.
Results:
Five RCTs involving exercise were identified, involving 218 participants. No dual-tasking studies were suitable. Pairwise comparisons favoured tango and mixed-treadmill training (TT) when compared to control, however 95% Confidence Intervals (CI) crossed the line of no effect (MD = 0). Indirect comparisons revealed tango had clinically meaningful reductions in Part I scores compared to speed-TT and body-weight resistance training, (MD -4.47; 95% CI -8.50 to -0.44 and MD -4.38; 95% CI -7.86 to -0.90), indicating improved NMeDL. Compared to control, low confidence evidence suggests tango and mixed-TT improves NMeDL.
Conclusions:
Tango and mixed-TT are the most effective exercise interventions for improving NMeDL. Adoption of an exercise program in the early stages of PD, irrespective of modality, may be effective and holds potential clinical importance immediately following a diagnosis of PD.Other: Prospero Registration Number; CRD42022322470.
... There is increasing evidence and marked interest for non-pharmacological interventions in people with Parkinson's disease (PD), especially exercise [1]. Moderate-to high-intensity exercise has beneficial effects on motor symptoms [2,3] with seemingly the most potent effect from high-intensity exercise [2,4]. ...
Despite increasing evidence on exercise in Parkinson’s disease (PD) it remains unclear what type and intensity of exercise are most effective. Currently, most evidence favors moderate- to high-intensity aerobic exercise for its positive effects on motor symptoms as well as disease modifying potential. On the other hand, observational studies have shown that the sheer volume of exercise matters as well, independent of intensity. So far, the efficacy of the volume of exercise has not been confirmed by randomized controlled trials (RCTs). Here, we provide an overview of the ongoing RCTs that promote physical activity in daily life in PD. We found seven RCTs with sample sizes between 30 and 452 and a follow-up between 4 weeks and 12 months. Steps per day is the most commonly reported primary outcome measure. The ongoing RCTs will provide evidence for feasibility, whereafter the PD research field is ready for a next step and to explore the effect of physical activity on disease progression and PD symptoms.
... Another intervention-sensory-motor training for airway protection (smTAP)-improves measures of reflexive cough including flow rate, volume, and urgeto-cough [29 ••]. Additionally, video-assisted swallow therapy (VAST), which uses endoscopy-facilitated biofeedback to encourage implicit modifications of swallowing physiology, has been assessed [44,45]. VAST demonstrated improved pharyngeal clearance and SWAL-QOL scores [45]. ...
Purpose of Review
Dysphagia is highly prevalent in Parkinson disease (PD) but is not typically identified nor treated until later in the disease process. This review summarizes current pharmacological, surgical, and behavioral treatments for PD-associated dysphagia and contributions from translational animal research.
Recent Findings
Swallowing is a complex physiologic process controlled by multiple brain regions and neurotransmitter systems. As such, interventions that target nigrostriatal dopamine dysfunction have limited or detrimental effects on swallowing outcomes. Behavioral interventions can help target PD-associated dysphagia in mid-to-late stages. Animal research is necessary to refine treatments and useful in studying prodromal dysphagia.
Summary
Dysphagia is an early, common, and debilitating sign of PD. Current pharmacological and surgical interventions are not effective in ameliorating swallowing dysfunction; behavioral intervention remains the most effective approach for dysphagia treatment. Animal research has advanced our understanding of mechanisms underlying PD and PD-associated dysphagia, and continues to show translational promise for the study of dysphagia treatment options.
... These therapeutic interventions have attracted great interest in both the scienti¯c and clinical communities in the last few years. [7][8][9] Among them, acoustic stimulation in the audio range is an easy and affordable therapy that has shown a great potential to produce motor and nonmotor e®ects that could bene¯cial for PD patients. ...
This paper describes a longitudinal study to analyze the effects of acoustic stimulation with Binaural Beats (BBs) at 14[Formula: see text]Hz (beta band) in patients with Parkinson's Disease (PD). Participants ([Formula: see text], age [Formula: see text], stage [Formula: see text] Hoehn and Yahr scale) listened to binaural stimulation for 10[Formula: see text]min a day, 3 days a week, during six months and were assessed 3 times during this period using electroencephalography (EEG), cognitive (PD-CRS), quality of life (PDQ-39) and wearing-off (WOQ-19) tests. During each assessment (basal, and after 3 and 6 months), the relative power in theta band was analyzed before, during and after the stimulation. Focusing the analysis on the motor cortex, the results obtained have confirmed the initial hypothesis for the first session, but they have shown a habituation effect which decreases its efficiency with time. Also, different reactions have been detected among individuals, with some reacting as expected from the beginning, while others would react in an opposite way at the beginning but they have shown afterwards a tendency towards the expected outcome. Anyhow, the relative power of the theta band was reduced between the first and the last session for more than half of the participants, although with very different values. Subtle changes have also been observed in some items of the PD-CRS, PDQ-39 and WOQ-19 tests.
... Management of PD primarily focuses on symptom control, often through multiple medications at different times each day [10]. Additionally, non-pharmacological treatments may be recommended in conjunction with pharmacological treatment in PD [11]. For example, exercise and physical activity supported by physiotherapists and appropriate referral to a multidisciplinary team including an occupational therapist, speech and language therapist or dietician can help manage the progressive symptoms of PD [12]. ...
Background:
People with long-term conditions must complete many healthcare tasks such as take medications, attend appointments, and change their lifestyle. This treatment burden and ability to manage it (capacity) is not well-researched in Parkinson's disease.
Objective:
To explore and identify potentially modifiable factors contributing to treatment burden and capacity in people with Parkinson's disease and caregivers.
Methods:
Semi-structured interviews with nine people with Parkinson's disease and eight caregivers recruited from Parkinson's disease clinics in England (ages 59-84 years, duration of Parkinson's disease diagnosis 1-17 years, Hoehn and Yahr (severity of Parkinson's disease) stages 1-4) were conducted. Interviews were recorded and analyzed thematically.
Results:
Four themes of treatment burden with modifiable factors were identified: 1) Challenges with appointments and healthcare access: organizing appointments, seeking help and advice, interactions with healthcare professionals, and caregiver role during appointments; 2) Issues obtaining satisfactory information: sourcing and understanding information, and satisfaction with information provision; 3) Managing medications: getting prescriptions right, organizing polypharmacy, and autonomy to adjust treatments; and 4) Lifestyle changes: exercise, dietary changes, and financial expenses. Aspects of capacity included access to car and technology, health literacy, financial capacity, physical and mental ability, personal attributes and life circumstances, and support from social networks.
Conclusions:
There are potentially modifiable factors of treatment burden including addressing the frequency of appointments, improving healthcare interactions and continuity of care, improving health literacy and information provision, and reducing polypharmacy. Some changes could be implemented at individual and system levels to reduce treatment burden for people with Parkinson's and their caregivers. Recognition of these by healthcare professionals and adopting a patient-centered approach may improve health outcomes in Parkinson's disease.
... The conducted body of research showed an improvement in the ability to work in individual areas of the brain by improving the speed of processing the provided data. All of these activities lead to the possibility of more detailed work in the brain and beneficial changes in functional areas [64][65][66]. ...
The purpose of this publication is to provide generalized knowledge of the area of changes that took place over past centuries in relation to health, social and cultural conditions. In Greek mythology, it was necessary to nurture both body and spirit to be a perfect human being. This link between the concepts of physical beauty and goodness can be also found in later works dedicated to ancient Greek history. Particularly in Greek myths, and in Greek education in general, it was believed that both physical and spiritual excellence were necessary to raise men to achieve their true form.
... In addition, non-motor symptoms such as cognitive problems, sleep disorders, autonomic dysfunction and sensory problems are also commonly experienced [4]. Both pharmacological [5] and non-pharmacological [6] therapies can be used to manage the disease. So far, however, there is no disease-modifying treatment available [7]. ...
Background:
Parkinson's disease (PD) is a progressive neurodegenerative disease with a fast increasing prevalence. Several pharmacological and non-pharmacological interventions are available to alleviate symptoms. Technology can be used to improve the efficiency, accessibility and feasibility of these treatments. Although many technologies are available, only few are actually implemented in daily clinical practice.
Aim:
Here, we study the barriers and facilitators, as experienced by patients, caregivers and/or healthcare providers, to successful implement technology for PD management.
Methods:
We performed a systematic literature search in the PubMed and Embase databases until June 2022. Two independent raters screened the titles, abstracts and full texts on: 1) people with PD; 2) using technology for disease management; 3) qualitative research methods providing patients', caregivers and/or healthcare providers' perspective, and; 4) full text available in English or Dutch. Case studies, reviews and conference abstracts were excluded.
Results:
We found 5420 unique articles of which 34 were included in this study. Five categories were made: cueing (n = 3), exergaming (n = 3), remote monitoring using wearable sensors (n = 10), telerehabilitation (n = 8) and remote consultation (n = 10). The main barriers reported across categories were unfamiliarity with technology, high costs, technical issues and (motor) symptoms hampering the use of some technologies. Facilitators included good usability, experiencing beneficial effects and feeling safe whilst using the technology.
Conclusion:
Although only few articles presented a qualitative evaluation of technologies, we found some important barriers and facilitators that may help to bridge the gap between the fast developing technological world and actual implementation in day-to-day living with PD.
... Rehabilitation, aerobic and resistance exercise, physiotherapy, and exercises such as tai chi and yoga are gaining increasing attention and have the advantages of being enjoyable for individuals, economically feasible, and culturally integrated within communities. 41 Counseling on sleep, diet, and mind-body approaches, such as meditation, should be explored as well as engagement in community or research, where available. However, very few patients are referred to therapists who have the skills for these types of multidisciplinary interventions. ...
... 3. Music, as a tool of fragility During the last decade, there has been a growing interest and progress in the adoption of music as a therapeutic tool in neurological rehabilitation and many new music-based methods have been developed to improve motor, cognitive, linguistic, emotional and social deficits in people suffering from a debilitating neurological disease, ranging from childhood-adolescence as in cases of autism (Geretsegger et al., 2014) and dyslexia (Flaugnacco et al., 2015), up to adulthood with cases of stroke patients (Bradt & Dileo, 2010;Rodríguez-Fornells et al., 2012;Altenmüller & Schlaug, 2015;Särkämö et al., 2016), Parkinson's disease (Nombela et al., 2013;Bloem et al., 2015) and dementia (Baird & Samson, 2015). In healthy patients, listening to music improves neuronal connectivity, while musical activities, such as learning to play an instrument, promote brain plasticity and induce changes in gray and white matter in different brain areas and especially in frontotemporal ones. ...
This contribution aims to offer food for thought on the ancestral role of music for
mankind, considering its potential, transversal to different areas of interest, including
psycho-pedagogical, clinical and didactic, as a heterogeneous expression of cultures,
communities and characters. In spite of the fact that music education is compulsory in
secondary schools, not in all contexts the activities are structured and carried out taking
into account the positive implications on pupils’ psycho-physical well-being, rehabilitative potential and increased motivation to learn. Just as the possibilities for dynamics
and time in music are manifold, so too is the horizon of options that looms over the sky of
educational action, intersecting also with the world of technology, which puts innovative
tools such as serious games at the service of education.
... It is characterized by gradual decline in not only motor functions but also non-motor functions such as cognitive and emotional disturbances [3]. Alongside the wellrecognized motor features of PD including resting tremor, muscular rigidity, bradykinesia, gait impairment, freezing, and postural instability [4,5], speech and communication skills are often affected [6] and cognitive impairments, depression, and anxiety are also prevalent in PD patients [7,8]. Consequently, all these symptoms could substantially affect quality of life and well-being in individuals with PD [9]. ...
This systematic review and meta-analysis examined previous studies on music-based interventions for individuals with Parkinson’s disease (PD). The effectiveness of the interventions on various motor and non-motor outcomes was evaluated. This review was conducted by searching PubMed, CINAHL, PsycINFO, and Cochrane Library CENTRAL prior to June 2022 for randomized controlled trial (RCT) and controlled clinical trial (CCT) studies published in English. Data were expressed as weighted/standardized mean difference (MD/SMD) with 95% confidence intervals (CI). I2 index was used for heterogeneity. The initial search identified 745 studies, and 13 studies involving 417 participants with PD which met the inclusion criteria included in this review. The results of the meta-analysis revealed that music-based interventions can significantly improve walking velocity (MD = 0.12, 95% CI = 0.07~0.16, p < 0.00001), stride length (MD = 0.04, 95% CI = 0.02~0.07, p = 0.002), and mobility (MD = −1.05, 95% CI = −1.53~−0.57, p < 0.0001). However, the results did not support significant effects for music-based interventions on cadence (MD = 3.21, 95% CI = −4.15~10.57, p = 0.39), cognitive flexibility (MD = 20.91, 95% CI = −10.62~52.44, p = 0.19), inhibition (SMD = 0.07, 95% CI = −0.40~0.55, p = 0.76), and quality of life (SMD = −0.68, 95% CI= −1.68~0.32, p = 0.18). The findings suggest that music-based interventions are effective for the improvement of some motor symptoms, but evidence for non-motor symptoms is limited. Further high-quality studies with a larger sample size are required to obtain the robust effects of music-based interventions on various outcomes among patients with PD.
... Over the past 20 years, a substantial amount of research has been conducted on both pharmacological and non-pharmacological treatment options for walking impairments in PD (Smulders et al., 2016;Debû et al., 2018;Ni et al., 2018;Radder et al., 2020). Especially in the later stages of PD, as pharmacological treatment effects become increasingly insufficient, rehabilitation and physical training programs have been identified to have a crucial complementary role in improving motor symptoms, including impaired walking (reviewed in (Bloem et al., 2015;Dietrichs and Odin, 2017;Domingos et al., 2018). Since DT walking situations can be dailyrelevant for individuals with PD, DT interventions have been evaluated over the past years-with promising results mainly from a multi-centered randomized controlled trial with 120 patients with PD (Strouwen et al., 2017;Geroin et al., 2018;Strouwen et al., 2019). ...
Introduction
Links between cognition and walking performance in patients with Parkinson’s disease (PD), which both decline with disease progression, are well known. There is lack of knowledge regarding the predictive value of cognition for changes in walking performance after individualized therapy. The aim of this study is to identify relevant predictive cognitive and affective parameters, measurable in daily clinical routines, for change in quantitative walking performance after early geriatric rehabilitation.
Methods
Forty-seven acutely hospitalized patients with advanced PD were assessed at baseline (T1) and at the end (T2) of a 2-week early rehabilitative geriatric complex treatment (ERGCT). Global cognitive performance (Montreal Cognitive Assessment, MoCA), EF and divided attention (Trail Making Test B minus A, delta TMT), depressive symptoms, and fear of falling were assessed at T1. Change in walking performance was determined by the difference in quantitative walking parameters extracted from a sensor-based movement analysis over 20 m straight walking in single (ST, fast and normal pace) and dual task (DT, with secondary cognitive, respectively, motor task) conditions between T1 and T2. Bayesian regression (using Bayes Factor BF 10 ) and multiple linear regression models were used to determine the association of non-motor characteristics for change in walking performance.
Results
Under ST, there was moderate evidence (BF 10 = 7.8, respectively, BF 10 = 4.4) that lower performance in the ∆TMT at baseline is associated with lower reduction of step time asymmetry after treatment ( R ² adj = 0.26, p ≤ 0.008, respectively, R ² adj = 0.18, p ≤ 0.009). Under DT walking-cognitive, there was strong evidence (BF 10 = 29.9, respectively, BF 10 = 27.9) that lower performance in the ∆TMT is associated with more reduced stride time and double limb support ( R ² adj = 0.62, p ≤ 0.002, respectively, R ² adj = 0.51, p ≤ 0.009). There was moderate evidence (BF 10 = 5.1) that a higher MoCA total score was associated with increased gait speed after treatment ( R ² adj = 0.30, p ≤ 0.02).
Discussion
Our results indicate that the effect of ERGT on change in walking performance is limited for patients with deficits in EF and divided attention. However, these patients also seem to walk more cautiously after treatment in walking situations with additional cognitive demand. Therefore, future development of individualized treatment algorithms is required, which address individual needs of these vulnerable patients.
... 3. Music, as a tool of fragility During the last decade, there has been a growing interest and progress in the adoption of music as a therapeutic tool in neurological rehabilitation and many new music-based methods have been developed to improve motor, cognitive, linguistic, emotional and social deficits in people suffering from a debilitating neurological disease, ranging from childhood-adolescence as in cases of autism (Geretsegger et al., 2014) and dyslexia (Flaugnacco et al., 2015), up to adulthood with cases of stroke patients (Bradt & Dileo, 2010;Rodríguez-Fornells et al., 2012;Altenmüller & Schlaug, 2015;Särkämö et al., 2016), Parkinson's disease (Nombela et al., 2013;Bloem et al., 2015) and dementia (Baird & Samson, 2015). In healthy patients, listening to music improves neuronal connectivity, while musical activities, such as learning to play an instrument, promote brain plasticity and induce changes in gray and white matter in different brain areas and especially in frontotemporal ones. ...
This contribution aims to offer food for thought on the ancestral role of music for mankind, considering its potential, transversal to different areas of interest, including psycho-pedagogical, clinical and didactic, as a heterogeneous expression of cultures, communities and characters. In spite of the fact that music education is compulsory in secondary schools, not in all contexts the activities are structured and carried out taking into account the positive implications on pupils’ psycho-physical well-being, rehabilitative potential and increased motivation to learn. Just as the possibilities for dynamics and time in music are manifold, so too is the horizon of options that looms over the sky of educational action, intersecting also with the world of technology, which puts innovative tools such as serious games at the service of education.
... An increasing number of studies have examined the impact of non-pharmacological/nonsurgical supportive "activating" therapies, which include physical exercise, dance classes, and speech therapy [405]. Exercise improved the level of physical and mental functioning and quality of life of patients with PD [406][407][408][409][410]. Treadmill training, dance and yoga can significantly improve gait parameters, other motor performance and overall quality of life [411][412][413]. ...
An increasing number of the population all around the world suffer from age-associated neurodegenerative diseases including Parkinson's disease (PD). This disorder presents different signs of genetic, epigenetic and environmental origin, and molecular, cellular and intracellular dysfunction. At the molecular level, α-synuclein (αSyn) was identified as the principal molecule constituting the Lewy bodies (LB). The gut microbiota participates in the pathogenesis of PD and may contribute to the loss of dopaminergic neurons through mitochondrial dysfunction. The most important pathogenetic link is an imbalance of Ca2+ ions, which is associated with redox imbalance in the cells and increased generation of reactive oxygen species (ROS). In this review, genetic, epigenetic and environmental factors that cause these disorders and their cause-and-effect relationships are considered. As a constituent of environmental factors, the example of organophosphates (OPs) is also reviewed. The role of endothelial damage in the pathogenesis of PD is discussed, and a 'triple hit hypothesis' is proposed as a modification of Braak's dual hit one. In the absence of effective therapies for neurodegenerative diseases, more and more evidence is emerging about the positive impact of nutritional structure and healthy lifestyle on the state of blood vessels and the risk of developing these diseases.
Gait impairments are among the most common and disabling symptoms of Parkinson’s disease and worsen as the disease progresses. Early detection and diagnosis of subtype-specific gait deficits, as well as progression monitoring, can help to implement effective and preventive personalized treatment for PD patients. Yet, the gait features have not been fully studied in PD and its motor subtypes. To characterize comprehensive and objective gait alterations and to identify the potential gait biomarkers for early diagnosis, subtype differentiation, and disease severity monitoring. We analyzed gait parameters related to upper/lower limbs, trunk and lumbar, and postural transitions from 24 tremor-dominant (TD) and 20 postural instability gait difficulty (PIGD) dominant PD patients who were in early stage and 39 matched healthy controls (HC) during the Timed Up and Go test using wearable sensors. Results show: (1) Both TD and PIGD groups showed restricted backswing range in bilateral lower extremities and more affected side (MAS) arm, reduced trunk and lumbar rotation range in the coronal plane, and low turning efficiency. The receiver operating characteristic (ROC) analysis revealed these objective gait features had high discriminative value in distinguishing both PD subtypes from the HC with the area under the curve (AUC) values of 0.7~0.9 ( p < 0.01). (2) Subtle but measurable gait differences existed between TD and PIGD patients before the onset of clinically apparent gait impairment. (3) Specific gait parameters were significantly associated with disease severity in TD and PIGD subtypes. Objective gait biomarkers based on wearable sensors may facilitate timely and personalized gait treatments in PD subtypes through early diagnosis, subtype differentiation, and disease severity monitoring.
Parkinson’s disease (PD) is a common neurodegenerative disease that manifests as a various movement disorders: tremor, rigidity and postural instability. These dysfunctions can significantly impact the individual’s quality of life, leading to a decline in overall well-being. However, recent innovations in medical devices field promise additional methods to alleviate PD symptoms. The VILIM Ball is a local hand-arm stimulation device that generates mechanical vibrations within the frequency range of 8–18 Hz. It was shown in this study that Parkinson’s disease patients (PD) may experience enhanced upper limb functionality and reduction in tremor power through physiotherapy in conjunction to therapy with VILIM Ball device. A total of 24 participants were recruited and divided into two groups: the control group (N= 12) underwent physiotherapy alone, while the experimental group (N= 12) received physiotherapy in combination with the VILIM Ball. Hand coordination, tremor power, and the right-hand grip strength before and after interventions were assessed to quantify the effects of the interventions. The right-hand tremor power decreased by an average of 7.38% for the control group and by an average of 48.11% for the experimental group. The left-hand tremor power increased by 3.89% for the control group and decreased by the 30.23% for the experimental group. There were no significant changes in the right-hand grip strength after the interventions. These findings indicate that the local hand-arm vibration provided by the VILIM Ball in conjunction to physiotherapy can benefit patients more than the physiotherapy alone.
The inpatient Parkinson’s disease multimodal complex treatment (PD-MCT) was applied more than 15,000 times in 2022, in Germany. This number is increasing as is Parkinson’s disease (PD), which affects more than 400,000 people in Germany and leads to 100,000 disability-adjusted life years. In recent years, several observational studies have been conducted on the effectiveness of this kind of multidisciplinary care.
To summarize and discuss the evidence on the nature, benefits and potential of PD-MCT.
A narrative review of selected empirical findings was carried out.
The PD-MCT frequently lasts for 2–3 weeks and aims to maintain the quality of life of people with PD. Disease symptoms and activities of daily living are jointly improved by pharmacological strategies and activating therapies (physiotherapy, occupational therapy, speech and language therapy, physical training, art therapy). The PD-MCT is a useful measure to avoid or mitigate crisis situations in the course of the disease. A total of eight observational studies (n = 1246) have shown good effectiveness with a total mean improvement of the International Parkinson and Movement Disorder Society unified Parkinson’s disease rating scale III (MDS-UPDRS III) by 7.8 points. The transfer of effects into everyday life through intensive and specialized community-based care must be ensured in order to achieve sustained effects on the quality of life. Ideally, this transfer can be supported by integrated PD networks and digital technologies in the future.
There is potential for development in the standardization, patient selection and quality assurance of PD-MCT as well as in the embedding in care structures such as PD networks. Open research questions include a precise definition of the target group and higher quality evidence of short-term and long-term effectiveness.
Introduction
Gait and mobility impairment are pivotal signs of parkinsonism, and they are particularly severe in atypical parkinsonian disorders including multiple system atrophy (MSA) and progressive supranuclear palsy (PSP). A pilot study demonstrated a significant improvement of gait in patients with MSA of parkinsonian type (MSA-P) after physiotherapy and matching home-based exercise, as reflected by sensor-based gait parameters. In this study, we aim to investigate whether a gait-focused physiotherapy (GPT) and matching home-based exercise lead to a greater improvement of gait performance compared with a standard physiotherapy/home-based exercise programme (standard physiotherapy, SPT).
Methods and analysis
This protocol was deployed to evaluate the effects of a GPT versus an active control undergoing SPT and matching home-based exercise with regard to laboratory gait parameters, physical activity measures and clinical scales in patients with Parkinson’s disease (PD), MSA-P and PSP. The primary outcomes of the trial are sensor-based laboratory gait parameters, while the secondary outcome measures comprise real-world derived parameters, clinical rating scales and patient questionnaires. We aim to enrol 48 patients per disease group into this double-blind, randomised-controlled trial. The study starts with a 1 week wearable sensor-based monitoring of physical activity. After randomisation, patients undergo a 2 week daily inpatient physiotherapy, followed by 5 week matching unsupervised home-based training. A 1 week physical activity monitoring is repeated during the last week of intervention.
Ethics and dissemination
This study, registered as ‘Mobility in Atypical Parkinsonism: a Trial of Physiotherapy (Mobility_APP)’ at clinicaltrials.gov ( NCT04608604 ), received ethics approval by local committees of the involved centres. The patient’s recruitment takes place at the Movement Disorders Units of Innsbruck (Austria), Erlangen (Germany), Lausanne (Switzerland), Luxembourg (Luxembourg) and Bolzano (Italy). The data resulting from this project will be submitted to peer-reviewed journals, presented at international congresses and made publicly available at the end of the trial.
Trial registration number
NCT04608604 .
Music is a powerful stimulus to our brain and not only an excellent source of enjoyment, learning or relaxing. During the last 20 years there is new considerable evidence of the extensive neural circuits involved in music processing and the morphologic, neurochemical and electrophysiological changes that music can induce. Our population is aging and there will be an increase in the prevalence for neurodegenerative conditions like dementias that still have no cure. There is
consequently an urgent need to develop treatments and activities that may alleviate the symptoms of dementia. Accumulating evidence shows that persons with dementia enjoy music, and their ability to respond to music is potentially preserved even in the late or severe stages of dementia when verbal communication may have ceased. Even though the diverse studies reporting benefits of music therapy in conditions such as Dementia, Parkinson, Epilepsy, Cancer, etc. have important
methodologic flaws, Music can have a role as a therapeutic tool in these conditions. Herein, we analyze the current evidence that may support the use of Music in different conditions in Medicine.
The discovery of a pathogenic variant in the alpha-synuclein (SNCA) gene in the Contursi kindred in 1997 indisputably confirmed a genetic cause in a subset of Parkinson’s disease (PD) patients. Currently, pathogenic variants in one of the seven established PD genes or the strongest known risk factor gene, GBA1, are identified in ∼15% of PD patients unselected for age at onset and family history. At first sight, the steep increase in PD prevalence exceeding that of other neurodegenerative diseases may argue against a predominant genetic etiology. Notably, the principal genetic contribution in PD is conferred by pathogenic variants in LRRK2 and GBA1 and, in both cases, characterized by an overall late age of onset and age-related penetrance. In addition, polygenic risk plays a considerable role in PD. However, it is likely that, in the majority of PD patients, a complex interplay of aging, genetic, environmental, and epigenetic factors leads to disease development.5% of PD patients unselected for age at onset and family history. At first sight, the steep increase in PD prevalence exceeding that of other neurodegenerative diseases may argue against a predominant genetic etiology. Notably, the principal genetic contribution in PD is conferred by pathogenic variants in LRRK2 and GBA1 and, in both cases, characterized by an overall late age of onset and age-related penetrance. In addition, polygenic risk plays a considerable role in PD. However, it is likely that, in the majority of PD patients, a complex interplay of aging, genetic, environmental, and epigenetic factors leads to disease development.
Background
‘PD Warrior’ (PDW) is a popular exercise program for Parkinson's disease; however, there are no published studies on the outcomes of the program.
Aims
To investigate short‐term functional and quality of life (QoL) outcomes after the PDW 10‐week program in a pilot study of individuals with early Parkinson's Disease (PD).
Methods
Twenty individuals with PD (Hoehn & Yahr 1–3) attending a hospital outpatient clinic were recruited into the PDW 10‐week program, comprising a weekly 1‐h supervised class complemented by an individualised daily home exercise program. Participants had the following assessments at baseline and after completion of the program: Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS‐UPDRS) Part III, timed up‐and‐go (TUG), 10‐m walk test (10mWT), 6‐min walking test (6MWT), balance tests, fine motor skills, 7‐day Parkinson's KinetiGraph (PKG) and PDQ‐39 QoL scale.
Results
Seventeen individuals completed the program. Significant improvements were observed in MDS‐UPDRS motor score ( P = 0.019, d = 0.68, MCID 7); 6MWT distance ( P < 0.001, d = 1.16); walking time during motor or cognitive dual tasking ( P = 0.006, d = 0.77; P = 0.005, d = 0.79, respectively); and the PDQ‐39 emotional well‐being subdomain ( P = 0.009; MCID 4.2); as well as improvements trending to significance in bradykinesia ( P = 0.025, d = 0.73), 10mWT walking time ( P = 0.023, d = 0.61) and borderline improvement in balance ( P = 0.056, d = 0.50).
Conclusions
The outcomes of this study support the efficacy of the PDW program in individuals with early PD and provide justification for future trials and investigation of its effects.
Background
In persons with Parkinson’s disease (PD) or certain forms of atypical parkinsonism, orthostatic hypotension is common and disabling, yet often underrecognized and undertreated. About half of affected individuals also exhibit supine hypertension. This common co-occurrence of both orthostatic hypotension and supine hypertension complicates pharmacological treatments as the treatment of the one can aggravate the other. Whole-body head-up tilt sleeping (HUTS) is the only known intervention that may improve both. Evidence on its effectiveness and tolerability is, however, lacking, and little is known about the implementability.
Methods
In this double-blind multicenter randomized controlled trial (phase II) we will test the efficacy and tolerability of HUTS at different angles in 50 people with PD or parkinsonism who have both symptomatic orthostatic hypotension and supine hypertension. All participants start with one week of horizontal sleeping and subsequently sleep at three different angles, each maintained for two weeks. The exact intervention will vary between the randomly allocated groups. Specifically, the intervention group will consecutively sleep at 6°, 12° and 18°, while the delayed treatment group starts with a placebo angle (1°), followed by 6° and 12°. We will evaluate tolerability using questionnaires and compliance to the study protocol. The primary endpoint is the change in average overnight blood pressure measured by a 24-hour ambulatory blood pressure recording. Secondary outcomes include orthostatic blood pressure, orthostatic tolerance, supine blood pressure, nocturia and various other motor and non-motor tests and questionnaires.
Discussion
We hypothesize that HUTS can simultaneously alleviate orthostatic hypotension and supine hypertension, and that higher angles of HUTS are more effective but less tolerable. The Heads-Up trial will help to clarify the effectiveness, tolerability and feasibility of this intervention at home and can guide at-home implementation.
Trial registration
ClinicalTrials.gov NCT05551377; Date of registration: September 22, 2022.
Background:
Parkinson's disease (PD) is the second most common neurodegenerative disorder worldwide. Mindfulness and meditation therapies have been demonstrated as effective alternative treatments for patients with neurological disorders. However, the effects of mindfulness and meditation therapies on PD remain unclear. This meta-analysis investigated the effects of mindfulness and meditation therapies in PD patients.
Method:
A literature search was conducted using PubMed, Embase, Cochrane Library, and ClinicalTrials.gov for randomized controlled trials comparing mindfulness and meditation therapies with control treatments in patients with PD.
Results:
Nine articles involving eight trials were included, with a total of 337 patients. Our meta-analysis revealed that mindfulness and meditation therapies significantly improved Unified Parkinson's Disease Rating Scale Subscale III score [mean difference (MD) = -6.31, 95% confidence interval (95% CI) = -8.57 to -4.05) and cognitive function [standard mean difference (SMD) = 0.62, 95% CI = 0.23 to 1.02]. However, no significant differences were discovered between mindfulness therapies and control in gait velocity (MD = 0.05, 95% CI = -0.23 to 0.34), Parkinson's disease Questionnaire-39 summary index (MD = 0.51, 95% CI = -1.12 to 2.14), activities of daily living (SMD = -1.65, 95% CI = -3.74 to 0.45), depression (SMD = -0.43, 95% CI = -0.97 to 0.11), anxiety (SMD = -0.80, 95% CI = -1.78 to 0.19), pain (SMD = 0.79, 95% CI = -1.06 to 2.63), or sleep disturbance (SMD = -0.67, 95% CI = -1.58 to 0.24).
Conclusion:
Mindfulness and meditation therapies may serve as complementary and alternative treatments for PD patients.
Biperiden is an anticholinergic agent with central effects. It is used in Parkinson's syndromes and in the treatment of extrapyramidal symptoms that occur with the use of various agents (neuroleptics, antipsychotics). It causes anticholinergic syndrome in high doses. For this reason, therapeutic drug monitoring of biperiden is important. This study, it was aimed to develop a validated GC-MS method for the therapeutic monitoring of biperiden in human plasma. Biperiden and internal standard biperiden-d5 were extracted from plasma using the salt-assisted liquid-liquid extraction method. The method was validated according to the European Medicines Agency (EMA), Bioanalytical method validation guidelines. The lower limit of quantification of the developed method was chosen as 0.5 ng/mL. The calibration curve of biperiden for the method was validated between 0.5 and 15 ng/mL, showing correlation coefficients >0.99. In addition, the developed method was used for the therapeutic drug monitoring of biperiden in real patient plasma.
I Parkinsonismi sono un gruppo di disturbi del movimento classificate in forme secondarie e degenerative. La malattia di Parkinson è una forma degenerativa di Parkinsonismo dovuta alla degenerazione della sostanza nigra e alla perdita dei suoi neuroni dopaminergici. La dopamina da essi prodotta ha una funzione di modulazione dell'attività dei nuclei della base. La perdita di tale modulazione porta a una riduzione del movimento con aumento della rigidità, lentezza e parziale perdita di alcuni movimenti automatici: i riflessi posturali, la deambu- lazione e il pendolarismo. La L-Dopa a partire dalla fine degli anni '60 del Novecento ha permesso di curare questi pazienti con miglioramento della rigidità e della lentezza. La breve emivita di questo farmaco ha richiesto lo sviluppo di altre molecole che ne permettessero il prolungamento dell'azione. Purtroppo non sempre tali nuovi farmaci sono risultati efficaci o hanno causato importanti effetti collaterali. La riabilitazione si è rivelata essere efficace nel migliorare gli aspetti motori della malattia e nel migliorare la qualità di vita dei pazienti. Per tale ragione un approccio multidisciplinare e integrato è adesso consigliato come miglior trattamento dei pazienti con malattia di Parkinson.
Objective: Prior to implementing any robotic device or new rehabilitation technique into clinical practice, it is essential to examine metrics that reflect the instrument's utility and range of action. For this purpose, this study assesses, based on biomechanical data, the ergonomics and action range of a wrist exoskeleton that may be implemented into clinical practice for the rehabilitation of this joint in patients with Parkinson' disease (PD). Materials and Methods: Eleven individuals with rigidity caused by PD participated in the study. Two distinct tasks were proposed: maximum voluntary contraction and sequential wrist flexion and extension; while electromyography and kinematic data were collected in two stages, with and without the exoskeleton. For statistical analysis, Bootstrap resampling, Kolmogorov-Smirnov, and paired Wilcoxon Mann tests were used. Results and Conclusion: Using the exoskeleton resulted in a 22% increase in muscle activation of the carpal extensors and a 9% decrease in wrist extension. According to the biomechanical parameters evaluated, the exoskeleton guaranteed the amplitude considered functional for the wrist joint, indicating good mechanical adequacy for use in clinical practice.
People with Parkinson disease suffer from a loss of dopaminergic neurons, which are involved in walking speed. Currently, virtual reality (VR) has emerged as a useful tool for the rehabilitation of people with neurological diseases, optimizing results in balance and gait. This review aimed to evaluate the effectiveness of VR or video games (through face-to-face sessions and not telerehabilitation) in improving walking speed and other spatio-temporal parameters of gait, balance, and quality of life in patients with Parkinson disease. A bibliographic search was carried out in the MEDLINE, Web of Science, Scopus, and PEDro databases. This systematic review adhered to the PRISMA guideline statement and was registered in PROSPERO (CRD42020180836). From a total of 119 records, 5 studies met the inclusion criteria for qualitative analysis, of which 3 contributed to the meta-analysis; inconclusive findings were found on gait speed, balance, and quality of life after the use of non-immersive VR systems face-to-face. A greater number of studies are necessary, with a greater number of participants, to differentiate between those VR specific systems (specifically designed for rehabilitation) from commercial video games, including immersive systems, and obtain more conclusive evidence. Furthermore, it would be interesting to compare the administration of this treatment in person versus its administration via telerehabilitation, which will help plan treatment programs.
Parkinson’s disease (PD) is the most common age-related neurodegenerative movement disorder, affecting around 1.7% of the population over 65 years old in China. The pathological feature of PD is the accumulation of α-synuclein-containing intraneuronal inclusions and progressive loss of dopaminergic neurons in midbrains. PD is clinically characterized by both motor and non-motor symptoms. In the past 20 years, Chinese researchers and clinicians have made significant progress in understanding the pathogenesis of PD, discovering biomarkers for early diagnosis, and developing novel therapeutic strategies to combat this disease. Until now, the Chinese Society of Parkinson’s Disease and Movement Disorders have published four editions of the Chinese Parkinson’s Disease Treatment Guidelines in 2006, 2009, 2014, and 2020. In this chapter, we will describe the main contents of these guidelines and summarize recent progress of PD treatment in China.
Converging lines of evidence suggest that aerobic exercise impacts Parkinson’s disease (PD) motor symptoms and might slow it’s progression. We provide an overview of the ongoing randomized clinical trials (RCTs) on aerobic exercise in PD. We found six RCTs with sample sizes between 28 and 370 and a follow-up between 8 weeks and 18 months. PD motor symptoms is mostly used as primary outcome while various secondary outcomes are reported. We need more trials that use both clinical endpoints and markers of neuroplasticity, and provide insight into the optimal exercise mode, duration and intensity.
Background
There is insufficient evidence to support use of occupational therapy interventions for patients with Parkinson’s disease. We aimed to assess the efficacy of occupational therapy in improving daily activities of patients with Parkinson’s disease.
Methods
We did a multicentre, assessor-masked, randomised controlled clinical trial in ten hospitals in nine Dutch regional networks of specialised health-care professionals (ParkinsonNet), with assessment at 3 months and 6 months. Patients with Parkinson’s disease with self-reported difficulties in daily activities were included, along with their primary caregivers. Patients were randomly assigned (2:1) to the intervention or control group by a computer- generated minimisation algorithm. The intervention consisted of 10 weeks of home-based occupational therapy according to national practice guidelines; control individuals received usual care with no occupational therapy. The primary outcome was self-perceived performance in daily activities at 3 months, assessed with the Canadian Occupational Performance Measure (score 1–10). Data were analysed using linear mixed models for repeated measures (intention-to-treat principle). Assessors monitored safety by asking patients about any unusual health events during the preceding 3 months. This trial is registered with ClinicalTrials.gov, NCT01336127.
Findings
Between April 14, 2011, and Nov 2, 2012, 191 patients were randomly assigned to the intervention group (n=124) or the control group (n=67). 117 (94%) of 124 patients in the intervention group and 63 (94%) of 67 in the control group had a participating caregiver. At baseline, the median score on the Canadian Occupational Performance Measure was 4•3 (IQR 3•5–5•0) in the intervention group and 4•4 (3•8–5•0) in the control group. At 3 months, these
scores were 5•8 (5•0–6•4) and 4•6 (3•8–5•5), respectively. The adjusted mean difference in score between groups at 3 months was in favour of the intervention group (1•2; 95% CI 0•8–1•6; p<0•0001). There were no adverse events associated with the study.
Interpretation
Home-based, individualised occupational therapy led to an improvement in self-perceived performance in daily activities in patients with Parkinson’s disease. Further work should identify which factors related to the patient, environmental context, or therapist might predict which patients are most likely to benefit from occupational therapy.
Background:
A large randomized clinical trial (the Occupational Therapy in Parkinson's Disease [OTiP] study) recently demonstrated that home-based occupational therapy improves perceived performance in daily activities of people with Parkinson's disease (PD). The aim of the current study was to evaluate the cost-effectiveness of this intervention.
Methods:
We performed an economic evaluation over a 6-month period for both arms of the OTiP study. Participants were 191 community-dwelling PD patients and 180 primary caregivers. The intervention group (n = 124 patients) received 10 weeks of home-based occupational therapy; the control group (n = 67 patients) received usual care (no occupational therapy). Costs were assessed from a societal perspective including healthcare use, absence from work, informal care, and intervention costs. Health utilities were evaluated using EuroQol-5d. We estimated cost differences and cost utility using linear mixed models and presented the net monetary benefit at different values for willingness to pay per quality-adjusted life-year gained.
Results:
In our primary analysis, we excluded informal care hours because of substantial missing data for this item. The estimated mean total costs for the intervention group compared with controls were €125 lower for patients, €29 lower for caregivers, and €122 higher for patient-caregiver pairs (differences not significant). At a value of €40,000 per quality-adjusted life-year gained (reported threshold for PD), the net monetary benefit of the intervention per patient was €305 (P = 0.74), per caregiver €866 (P = 0.01) and per patient-caregiver pair €845 (P = 0.24).
Conclusion:
In conclusion, occupational therapy did not significantly impact on total costs compared with usual care. Positive cost-effectiveness of the intervention was only significant for caregivers. © 2015 International Parkinson and Movement Disorder Society.
Background. Novel rehabilitation strategies have demonstrated potential benefits for motor and non-motor symptoms of Parkinson’s disease (PD). Objective. To compare the effects of Lee Silverman Voice Therapy BIG (LSVT BIG therapy) versus a general exercise program (combined treadmill plus seated trunk and limb exercises) on motor and non-motor symptoms of PD. Methods. Eleven patients with early-mid stage PD participated in the prospective, double-blinded, randomized clinical trial. Both groups received 16 one-hour supervised training sessions over 4 weeks. Outcome measures included the Unified Parkinson’s Disease Rating Scale (UPDRS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Modified Fatigue Impact Scale (MFIS). Five patients performed general exercise and six patients performed LSVT BIG therapy. Post-intervention evaluations were conducted at weeks 4, 12 and 24. Results. The combined cohort made improvements at all follow-up evaluations with statistical significance for UPDRS total and motor, BDI, and MFIS (p<0.05). Conclusion. This study demonstrated positive effects of general exercise and LSVT BIG therapy on motor and non-motor symptoms of patients with PD. Our results suggest that general exercise may be as effective as LSVT BIG therapy on symptoms of PD for patients not able to readily access outpatient LSVT BIG therapy.
Exercise can improve motor function in people with Parkinson's disease but depression reduces the motivation to participate in regular exercise. The aim of this study was to develop a novel Enhanced Exercise Therapy program that uses manual-driven guided exercise and peer-facilitated psychoeducation for individuals with Parkinson's disease and depression.
24 week randomized controlled design.
Thirty individuals were randomized to Enhanced Exercise Therapy or self-guided therapy, and evaluated at baseline, 12-weeks and at 24-weeks. Enhanced Exercise Therapy included group exercise and group psychoeducation for 12 weeks. Between 13 and 24 weeks, individuals had access to the fitness facility but group sessions were not held. Self-guided therapy included written guidelines for a self-paced exercise program and psychoeducation. Primary outcome measures included the number of exercise sessions and International Physical Activity Questionnaire score. Secondary measures included resting heart rate, supine blood pressure, estimated VO2max and incidence of orthostatic hypotension.
Twenty four individuals completed the study (80% retention) and both groups attended similar number of exercise sessions. There were no significant changes in cardiovascular fitness measures but there was a significant increase in the amount of physical activity in the Enhanced Exercise Therapy group and a decrease in the self-guided therapy group during the post-intervention period.
Enhanced Exercise Therapy appears to promote engagement in an exercise program and more physical activity, even after group sessions were concluded in individuals with Parkinson's disease and depression.
Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
[Purpose] In this study, we examined the effects of virtual reality dance exercise on the balance, activities of daily living and depressive disorder status of Parkinson's disease patients. [Subjects] Twenty patients were assigned either the experimental group (n = 10) or the control group (n = 10). All participants received 30 minutes of neurodevelopment treatment and 15 minutes of functional electrical stimulation 5 times per week for 6 weeks. The experimental group additionally performed 30 minutes of dance exercise. Balance, activities of daily living, and depressive disorder status were assessed before and after the 6-week treatment period using the Berg balance scale, the Modified Barthel Index, and the Beck Depression Inventory. The paired t-test was used to detect differences before and after treatment, and the independent t-test was used to detect differences between the treatment groups. [Results] The values for balance, activities of daily living, and depressive disorder status significantly differed between before and after treatment in the experimental group, and significantly differed between the experimental group and control group. [Conclusion] Virtual reality dance exercise has a positive effect on balance, activities of daily living, and depressive disorder status of Parkinson's disease patients.
Physical rehabilitation is commonly used in patients with Parkinson's disease (PD) to improve their health and alleviate the symptoms.
We compared the effects of three programs, strength training (ST), aerobic training (AT), and physiotherapy, on motor symptoms, functional capacity, and electroencephalographic (EEG) activity in PD patients.
Twenty-two patients were recruited and randomized into three groups: AT (70% of maximum heart rate), ST (80% of one repetition maximum), and physiotherapy (in groups). Subjects participated in their respective interventions twice a week for 12 weeks. The assessments included measures of disease symptoms (Unified Parkinson's Disease Rating Scale [UPDRS]), functional capacity (Senior Fitness Test), and EEG before and after 12 weeks of intervention.
The PD motor symptoms (UPDRS-III) in the group of patients who performed ST and AT improved by 27.5% (effect size [ES]=1.25, confidence interval [CI]=-0.11, 2.25) and 35% (ES=1.34, CI=-0.16, 2.58), respectively, in contrast to the physiotherapy group, which showed a 2.9% improvement (ES=0.07, CI=-0.85, 0.99). Furthermore, the functional capacity of all three groups improved after the intervention. The mean frequency of the EEG analysis mainly showed the effect of the interventions on the groups (F=11.50, P=0.0001).
ST and AT in patients with PD are associated with improved outcomes in disease symptoms and functional capacity.
Background:
Highly challenging exercises have been suggested to induce neuroplasticity in individuals with Parkinson's disease (PD); however, its effect on clinical outcomes remains largely unknown.
Objective:
To evaluate the short-term effects of the HiBalance program, a highly challenging balance-training regimen that incorporates both dual-tasking and PD-specific balance components, compared with usual care in elderly with mild to moderate PD.
Methods:
Participants with PD (n = 100) were randomized, either to the 10-week HiBalance program (n = 51) or to the control group (n = 49). Participants were evaluated before and after the intervention. The main outcomes were balance performance (Mini-BESTest), gait velocity (during normal and dual-task gait), and concerns about falling (Falls Efficacy Scale-International). Performance of a cognitive task while walking, physical activity level (average steps per day), and activities of daily living were secondary outcomes.
Results:
A total of 91 participants completed the study. After the intervention, the between group comparison showed significantly improved balance and gait performance in the training group. Moreover, although no significant between group difference was observed regarding gait performance during dual-tasking; the participants in the training group improved their performance of the cognitive task while walking, as compared with the control group. Regarding physical activity levels and activities of daily living, in comparison to the control group, favorable results were found for the training group. No group differences were found for concerns about falling.
Conclusions:
The HiBalance program significantly benefited balance and gait abilities when compared with usual care and showed promising transfer effects to everyday living. Long-term follow-up assessments will further explore these effects.
To investigate if community-based Irish set dancing is feasible in Irish adults with Parkinson's disease.
Over an eight week period, ten participants attended one set dancing class per week and completed a home programme in parallel. Feasibility was assessed by monitoring adverse effects, participants' verbal feedback, compliance rates and feedback from an exit questionnaire. Participants were assessed using the Berg balance scale, 6-min walk test, UPDRS-3 and PDQ-39, before and after the intervention.
No adverse effects were detected. Attendance at classes was 86%. Compliance with the home programme was 67%. Findings from the exit questionnaire showed participants enjoyed participating and reported improvements in aspects of health including balance. Quality of life improved with the dance programme and there was a trend toward improvement on the UPDRS-3.
These findings suggest community-based Irish set dancing is a feasible form of exercise that can positively influence quality of life.
Copyright © 2014 Elsevier Ltd. All rights reserved.
Authors post-print full text copy available: http://ulir.ul.ie/handle/10344/4402
Physical exercise is a cornerstone in the management of many neurodegenerative disorders, such as Parkinson's disease, dementia, and stroke. However, much of its beneficial effects on improving motor functions and cognition as well as decreasing neurodegeneration and neuroinflammation are not yet well understood. The obvious limitations of studying the protective mechanisms behind exercise, for example, brain plasticity and neurodegeneration, could be overcome by generating novel animal models of neurodegenerative disorders. In this narrative review, we discuss the beneficial effects of exercise performed in animal models of neurodegenerative disorders and how the results from animal studies can be used in clinical settings. From preclinical studies, the positive effects of exercise have been related to increased levels of neurotrophic factors, elevated expression of anti-inflammatory cytokines, and reduced levels of pro-inflammatory cytokines and activated microglia. It is clear that parameters influencing the effect of exercise, such as intensity, still remain to be investigated in animal studies in order to find the optimal program that can be translated into exercise interventions for patients with neurodegenerative diseases.
© The Author(s) 2014.
Background: Exercise can be beneficial for cardiopulmonary, musculoskeletal or neurological systems, and other factors including mood, and may be beneficial in reducing fall risks, dementia and variables associated with quality of life (QOL). Parkinson′s disease (PD) produces progressive motor and cognitive deterioration that may leave those inflicted unable to participate in standard exercise programs. Alternative forms of exercise such as yoga may be successful in improving physical function, QOL and physiological variables for overall well-being.
Aim: This randomized controlled pilot study investigated the effectiveness of yoga intervention on physiological and health-related QOL measures in people with PD.
Methods and Materials: Thirteen people with stage 1-2 PD were randomized to either a yoga (n = 8) or a control group (n = 5). The yoga group participated in twice-weekly yoga sessions for 12 weeks. Participants were tested at baseline, and at 6 and 12 weeks using the Unified Parkinson′s Disease Rating Scale (UPDRS), clinical measures of health-related QOL and physiological measures.
Results: Significant improvement in UPDRS scores (P = .006), diastolic blood pressure (P = 0.036) and average forced vital capacity (P = 0.03) was noted in the yoga group over time. Changes between groups were also noted in two SF-36 subscales. Positive trends of improvement were noted in depression scores (P = 0.056), body weight (P = 0.056) and forced expiratory volume (P = 0.059). Yoga participants reported more positive symptom changes including immediate tremor reduction.
Conclusions: The results suggest that yoga may improve aspects of QOL and physiological functions in stages 1-2 PD. Future larger studies are needed to confirm and extend our findings of the effects of yoga in PD.
Objectives:
To examine the efficacy of an integrative cognitive training program (REHACOP) to improve cognition, clinical symptoms, and functional disability of patients with Parkinson disease (PD).
Methods:
Forty-two patients diagnosed with PD in Hoehn & Yahr stages 1 to 3 were randomly assigned to either the cognitive training group (REHACOP) or the control group (occupational activities) for 3 months (3 sessions, 60 min/wk). Primary outcomes were change on processing speed, verbal memory, visual memory, executive functioning, and theory of mind. Secondary outcomes included changes on neuropsychiatric symptoms, depression, apathy, and functional disability. The trial was registered with clinicaltrials.gov (NCT02118480).
Results:
No baseline group differences were found. Bootstrapped analysis of variance results showed significant differences in the mean change scores between the REHACOP group and control group in processing speed (0.13 [SE = 0.07] vs −0.15 [SE = 0.09], p = 0.025), visual memory (0.10 [SE = 0.10] vs −0.24 [SE = 0.09], p = 0.011), theory of mind (1.00 [SE = 0.37] vs −0.27 [SE = 0.29], p = 0.013), and functional disability (−5.15 [SE = 1.35] vs 0.53 [SE = 1.49], p = 0.012).
Conclusions:
Patients with PD receiving cognitive training with REHACOP demonstrated statistically significant and clinically meaningful changes in processing speed, visual memory, theory of mind, and functional disability. Future studies should consider the long-term effect of this type of intervention. These findings support the integration of cognitive training into the standard of care for patients with PD.
Classification of evidence:
This study provides Class II evidence that for patients with PD, an integrative cognitive training program improves processing speed, visual memory, theory of mind, and functional disability.
Gait disturbances are one of the principal and most incapacitating symptoms of Parkinson’s disease (PD). In addition, walking economy is impaired in PD patients and could contribute to excess fatigue in this population. An important number of studies have shown that treadmill training can improve kinematic parameters in PD patients. However, the effects of treadmill and overground walking on the walking economy remain unknown. The goal of this study was to explore the walking economy changes in response to a treadmill and an overground training program, as well as the differences in the walking economy during treadmill and overground walking. Twenty-two mild PD patients were randomly assigned to a treadmill or overground training group. The training program consisted of 5 weeks (3 sessions/week). We evaluated the energy expenditure of overground walking, before and after each of the training programs. The energy expenditure of treadmill walking (before the program) was also evaluated. The treadmill, but not the overground training program, lead to an improvement in the walking economy (the rate of oxygen consumed per distance during overground walking at a preferred speed) in PD patients. In addition, walking on a treadmill required more energy expenditure compared with overground walking at the same speed. This study provides evidence that in mild PD patients, treadmill training is more beneficial compared with that of walking overground, leading to a greater improvement in the walking economy. This finding is of clinical importance for the therapeutic administration of exercise in PD.
Background:
Although physical exercise improves motor aspects of Parkinson's disease (PD), it is not clear whether it may also have a neuroprotective effect. Objective. In this 2-year follow-up study, we determined whether intensive exercise in the early stages of the disease slows down PD progression.
Methods:
Forty newly diagnosed patients with PD were treated with rasagiline and randomly assigned to 2 groups: MIRT Group (two 28-day multidisciplinary intensive rehabilitation treatments [MIRT], at 1-year interval) and Control Group (only drug). In both groups, Unified Parkinson's Disease Rating Scale Section II (UPDRS II), UPDRS III, 6-minute walking test (6MWT), Timed Up-and-Go test (TUG); PD Disability Scale (PDDS), and l-dopa equivalents were assessed at baseline (T0), 6 months (T1), 1 year (T2), 18 months (T3), and 2 years (T4) later.
Results:
Over 2 years, UPDRS II, UPDRS III, TUG, and PDDS differentially progressed in the 2 groups: In the MIRT Group, all scores at T4 were better than at T0 (all Ps < .03). No changes were noted in the Control Group. l-dopa equivalent dosages increased significantly only in the Control Group (P = .0015), with a decrease in the percentages of patients in monotherapy (T1 40%; T2, T3, and T4 20%). In the MIRT Group, the percentages of such patients remained higher (T1 and T2 100%; T3 89%; T4 75%).
Conclusions:
These results suggest that MIRT might slow down the progression of motor decay, it might delay the need for increasing drug treatment, and thus, it might have a neuroprotective effect.
Objective. To examine the effects of technology-assisted balance and gait training on reducing falls in patients with Parkinson's disease (PD). Methods. Eligible subjects were randomly allocated to an experimental group given technology-assisted balance and gait training (BAL, n = 26) and an active control group undertaking strengthening exercises (CON, n = 25). The training in each group lasted for 3 months. The number of fallers and fall rate were used as primary outcomes, and single-leg-stance-time, latency of postural response to perturbation, self-selected gait velocity, and stride length as secondary outcomes. Fall incidence was recorded over 15 months after the baseline assessment (Pre). Other tests were performed at Pre, after 3-month intervention (Post3m), at 3 months (Post6m), and 12 months (Post15m) after treatment completion. Results. Forty-five subjects who completed the 3-month training were included in the data analysis. There were fewer fallers in the BAL than in the CON group at Post3m, Post6m, and Post15m (P < .05). In addition, the BAL group had lower fall rate than the CON group at Post3m and Post6m (incidence rate ratio: 0.111-0.188, P < .05), and marginally so at Post15m (incidence rate ratio: 0.407, P = .057). Compared with the CON subjects, the BAL subjects demonstrated greater reduction in the postural response latency and increase in the stride length against baseline at each assessment interval (P < .05), and marginally more increases of single-leg-stance-time at Post3m (P = .064), Post6m (P = .041) and Post15m (P = .087). Conclusions. Our positive findings provide evidence for the clinical use of technology-assisted balance and gait training in reducing falls in people with PD.
Objective:
Our aim was to evaluate the feasibility of a hydrotherapy treatment in patients with Parkinson's disease and the effectiveness of this treatment on balance parameters in comparison to a traditional land-based physical therapy.
Design:
A randomized single-blind controlled trial.
Setting:
Outpatients.
Subjects:
Thirty-four patients with Parkinson's disease in Hoehn-Yahr stage 2.5-3.
Intervention:
Group 1 hydrotherapy treatment, group 2 land-based rehabilitation treatment. The two groups underwent the same rehabilitation period (60 minutes of treatment, five days a week for two months).
Main measures:
The primary outcome measures were the centre of the pressure sway area recorded with open and closed eyes, using a stabilometric platform. Secondary outcome measures were Unified Parkinson's Disease Rating Scale II and III, Timed Up and Go Test, Berg Balance Scale, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, Falls diary and Parkinson's Disease Questionnaire-39.
Results:
Hydrotherapy treatment proved to be feasible and safe. Patients in both groups had a significant improvement in all outcome variables. There was a better improvement in patients who underwent hydrotherapy than in patients treated with land-based therapy in the centre of pressure sway area closed eyes (mean SD change: 45.4 SD64.9 vs. 6.9 SD45.3, p = 0.05), Berg Balance Scale (51.2 SD3.1 vs. 6.0 SD3.1, p = 0.005), Activities-specific Balance Confidence Scale (16.8 SD10.6 vs. 4.1 SD5.4, p = 0.0001), Falls Efficacy Scale (-5.9 SD4.8 vs. -1.9 SD1.4, p = 0.003), Parkinson's Disease Quetionnaire-39 (-18.4 SD12.9 vs. -8.0 SD7.0, p = 0.006) and falls diary (-2.4 SD2.2 vs. -0.4 SD0.5, p = 0.001).
Conclusion:
Our study suggests that hydrotherapy may constitute a possible treatment for balance dysfunction in Parkinsonian patients with moderate stage of disease.
There is insufficient evidence to support use of occupational therapy interventions for patients with Parkinson's disease. We aimed to assess the efficacy of occupational therapy in improving daily activities of patients with Parkinson's disease.
We did a multicentre, assessor-masked, randomised controlled clinical trial in ten hospitals in nine Dutch regional networks of specialised health-care professionals (ParkinsonNet), with assessment at 3 months and 6 months. Patients with Parkinson's disease with self-reported difficulties in daily activities were included, along with their primary caregivers. Patients were randomly assigned (2:1) to the intervention or control group by a computer-generated minimisation algorithm. The intervention consisted of 10 weeks of home-based occupational therapy according to national practice guidelines; control individuals received usual care with no occupational therapy. The primary outcome was self-perceived performance in daily activities at 3 months, assessed with the Canadian Occupational Performance Measure (score 1-10). Data were analysed using linear mixed models for repeated measures (intention-to-treat principle). Assessors monitored safety by asking patients about any unusual health events during the preceding 3 months. This trial is registered with ClinicalTrials.gov, NCT01336127.
Between April 14, 2011, and Nov 2, 2012, 191 patients were randomly assigned to the intervention group (n=124) or the control group (n=67). 117 (94%) of 124 patients in the intervention group and 63 (94%) of 67 in the control group had a participating caregiver. At baseline, the median score on the Canadian Occupational Performance Measure was 4·3 (IQR 3·5-5·0) in the intervention group and 4·4 (3·8-5·0) in the control group. At 3 months, these scores were 5·8 (5·0-6·4) and 4·6 (4·6-6·6), respectively. The adjusted mean difference in score from baseline between groups at 3 months was in favour of the intervention group (1·2; 95% CI 0·8-1·6; p<0·0001). There were no adverse events associated with the study.
Home-based, individualised occupational therapy led to an improvement in self-perceived performance in daily activities in patients with Parkinson's disease. Further work should identify which factors related to the patient, environmental context, or therapist might predict which patients are most likely to benefit from occupational therapy.
Prinses Beatrix Spierfonds and Parkinson Vereniging.
Objective
To assess the effects of postural rehabilitation (PR) on trunk asymmetry and balance, with and without Kinesio Taping (KT) of the back muscles as additional treatment.
Design
single blind randomized controlled trial, with 1-month follow-up.
Setting
ambulatory care in referral center.
Participants
20 patients with PD showing postural abnormalities of trunk, on the sagittal and/or coronal plane.
Interventions
Four weeks of patient-tailored proprioceptive and tactile stimulation, combined with stretching and postural reeducation, were provided to 13 subjects (PR), while 7 received no treatment (CG). Six out of 13 also underwent the application of KT strips to trunk muscles, according to the posture abnormality features.
Main Outcome Measures
Berg Balance scale, Timed Up and Go, degrees of trunk bending on the sagittal and coronal plane were assessed at the enrollment (T0), one (T1) and two months later (T2).
Results
At T1, all treated patients showed a significant improvement in the trunk posture both in the sagittal (p=.002) and coronal planes (p=.01), with respect to baseline. Moreover, they showed an improvement in measures of gait and balance (p<.01). Benefits persisted at T2, for all measures, except lateral trunk bend. No differences were found when comparing PR to KT groups.
Conclusions
The combination of active posture correction and trunk movements, muscle stretching and proprioceptive stimulation may usefully impact PD axial symptoms. Repeated training is advocated to avoid waning of the effect.
The aim of this study was to evaluate the efficacy of a group Cognitive Behavioural Therapy (CBT) treatment for depression and anxiety in Parkinson's disease (PD).
A waitlist-controlled trial design was used. Eighteen adults with PD and a comorbid DSM-IV-TR diagnosis of depression and/or anxiety were randomised to either Intervention (8-week group CBT treatment) or Waitlist (8-week clinical monitoring preceding treatment). The Depression, Anxiety, Stress Scale-21 (DASS-21) was the primary outcome. Assessments were completed at Time 1 (pretreatment), Time 2 (posttreatment/post-waitlist) and 1-month and 6-month follow-ups.
At Time 2, participants who received CBT reported greater reductions in depression (Mchange = -2.45) than Waitlist participants (Mchange = .29) and this effect was large, d = 1.12, p = .011. Large secondary effects on anxiety were also observed for CBT participants, d = .89, p = .025. All treatment gains were maintained and continued to improve during the follow-up period. At 6-month follow-up, significant and large effects were observed for both depression (d = 2.07) and anxiety (d = 2.26).
Group CBT appears to be an efficacious treatment approach for depression and anxiety in PD however further controlled trials with larger numbers of participants are required.Trial registration: Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12610000455066).
Background. Exercise may decrease the risk of Parkinson’s disease (PD) in humans and reduce PD symptoms in animal
models. The beneficial effects have been linked to increased levels of neurotrophic factors. Objective. We examined whether
intensive rehabilitation treatment reduces motor disability in patients in the early stages of PD and increases brain-derived
neurotrophic factor (BDNF) serum levels. Methods. Thirty participants in the early stages of PD treated with rasagiline
were randomly assigned to 3 hours of rehabilitation treatment that included aerobic exercise for 28 days (Group 1) or to
not therapy (control; Group 2). BDNF serum levels were assessed at time T0 (baseline, before treatment), T1 (10 days),
T2 (20 days), and T3 (28 days). At T0 and T3, we assessed the Unified Parkinson’s Disease Rating Scale (UPDRS) III in both
groups, as well as the UPDRS II and total, Berg Balance Scale, and 6-minute walking test only in Group 1. Results. BDNF
levels significantly increased at T1 in Group 1, an increase that was maintained throughout the treatment period. At T3
compared to T0, UPDRS III scores significantly improved in Group 1 along with scores for UPDRS II, total, Berg Balance
Scale, and 6-minute walking test. Conclusions. Intensive rehabilitation treatment increases the BDNF levels and improves
PD signs in patients in the early stages of the disease. These results are in line with studies on animal models of PD and
healthy subjects.
A previous randomized, controlled trial of tai chi showed improvements in objectively measured balance and other motor-related outcomes in patients with Parkinson's disease. This study evaluated whether patient-reported outcomes could be improved through exercise interventions and whether improvements were associated with clinical outcomes and exercise adherence. In a secondary analysis of the tai chi trial, patient-reported and clinical outcomes and exercise adherence measures were compared between tai chi and resistance training and between tai chi and stretching exercise. Patient-reported outcome measures were perceptions of health-related benefits resulting from participation, assessed by the Parkinson's Disease Questionnaire (PDQ-8) and Vitality Plus Scale (VPS). Clinical outcome measures included motor symptoms, assessed by a modified Unified Parkinson's Disease Rating Scale-Motor Examination (UPDRS-ME) and a 50-foot speed walk. Information on continuing exercise after the structured interventions were terminated was obtained at a 3-month postintervention follow-up. Tai chi participants reported significantly better improvement in the PDQ-8 (-5.77 points, P = 0.014) than did resistance training participants and in PDQ-8 (-9.56 points, P < 0.001) and VPS (2.80 points, P = 0.003) than did stretching participants. For tai chi, patient-reported improvement in the PDQ-8 and VPS was significantly correlated with their clinical outcomes of UPDRS-ME and a 50-foot walk, but these correlations were not statistically different from those shown for resistance training or stretching. However, patient-reported outcomes from tai chi training were associated with greater probability of continued exercise behavior than were either clinical outcomes or patient-reported outcomes from resistance training or stretching. Tai chi improved patient-reported perceptions of health-related benefits, which were found to be associated with a greater probability of exercise adherence. The findings indicate the potential of patient perceptions to drive exercise behavior after structured exercise programs are completed and the value of strengthening such perceptions in any behavioral intervention.
To determine whether physical activity may influence cognitive performance in patients with Parkinson's disease (PD) by measuring reaction times in patients participating in the Berlin BIG study.
randomized controlled trial, rater-blinded SETTING: ambulatory care PARTICIPANTS: 60 patients with mild to moderate PD were randomly allocated to three treatment arms. Outcome was measured at termination of training and at follow-up 16 weeks after baseline in 58 patients (completers).
patients received 16 hours of individual LSVT-BIG training (BIG, duration of treatment 4 weeks), 16 hours group training with Nordic Walking (WALK, duration of treatment 8 weeks) or non-supervised domestic exercise (HOME).
Cued (cRT) and non-cued (nRT) reaction times RESULTS: Differences between treatment groups for improvement of reaction times from baseline to intermediate and baseline to follow-up assessments were observed for cRT but not for nRT. Pairwise t-test comparisons revealed differences of change in cRT at both measurements between BIG and HOME (intermediate -52ms, 95% confidence interval: -84/-20, p 0.002; follow up 55ms, CI: -105/-6, p 0.030) and between WALK and HOME (intermediate -61ms, CI: -120/-2, p 0.042; follow up -78ms, CI: -136/-20, p 0.010) There was no difference between BIG and WALK (intermediate 9ms, CI: -49/67, p 0.742; follow-up 23, CI: -27/72, p 0.361).
Supervised physical exercise with LSVT-BIG or Nordic Walking is associated with improvement of cognitive aspects of movement preparation.
ABSTRACT The authors determined effects of community-based adapted tango on spatial cognition and disease severity in Parkinson's disease (PD) while controlling for the effects of social interaction. Thirty-three individuals with mild-to-moderate PD (stage I-III) were assigned to twenty 90-min tango (n = 24) or education (n = 9) lessons over 12 weeks. Disease severity, spatial cognition, balance, and fall incidence were evaluated pre-, post-, and 10-12 weeks postintervention. The authors evaluated differences using t tests and analyses of variance. Twenty-three tango and 8 education participants finished. Tango participants improved on disease severity (p = .008), and spatial cognition (p = .021) compared with education participants. Tango participants also improved in balance (p = .038), and executive function (p = .012). Gains were maintained 10-12 weeks postintervention. Multimodal exercise with structured syllabi may improve disease severity and spatial cognition in PD.
To develop a method for cooperative human gait training, we investigated whether interactive rhythmic cues could improve the gait performance of Parkinson's disease patients. The interactive rhythmic cues ware generated based on the mutual entrainment between the patient's gait rhythms and the cue rhythms input to the patient while the patient walked. Previously, we found that the dynamic characteristics of stride interval fluctuation in Parkinson's disease patients were improved to a healthy 1/f fluctuation level using interactive rhythmic cues and that this effect was maintained in the short term. However, two problems remained in our previous study. First, it was not clear whether the key factor underpinning the effect was the mutual entrainment between the gait rhythms and the cue rhythms or the rhythmic cue fluctuation itself. Second, it was not clear whether or not the gait restoration was maintained longitudinally and was relearned after repeating the cue-based gait training. Thus, the present study clarified these issues using 32 patients who participated in a four-day experimental program. The patients were assigned randomly to one of four experimental groups with the following rhythmic cues: (a) interactive rhythmic cue, (b) fixed tempo cue, (c) 1/f fluctuating tempo cue, and (d) no cue. It has been reported that the 1/f fluctuation of stride interval in healthy gait is absent in Parkinson's disease patients. Therefore, we used this dynamic characteristic as an evaluation index to analyze gait relearning in the four different conditions. We observed a significant effect in condition (a) that the gait fluctuation of the patients gradually returned to a healthy 1/f fluctuation level, whereas this did not occur in the other conditions. This result suggests that the mutual entrainment can facilitate gait relearning effectively. It is expected that interactive rhythmic cues will be widely applicable in the fields of rehabilitation and assistive technology.
Multidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.
Objectives
(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.
Design
Pragmatic three-parallel group randomised controlled trial.
Setting
Community, county of Surrey, England, 2010–11.
Participants
People with Parkinson’s, at all stages of the disease, and live-in carers.
Interventions
Groups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).
Main outcome measures
Follow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.
Results
A total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,
n
= 102 (
n
= 61); group B,
n
= 101 (
n
= 60); group C,
n
= 103 (
n
= 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,
n
= 227 (live-in carers,
n
= 125)] [group A,
n
= 75 (
n
= 45); group B,
n
= 69 (
n
= 37); group C,
n
= 83 (
n
= 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (
p
= 0.02); their carers had improved psychological well-being (
p
= 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,
p
= 0.09), and improved non-motor symptoms (
p
= 0.06) and health-related quality of life (
p
= 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (
p
= 0.001); non-motor symptoms (
p
= 0.05); health-related quality of life (
p
= 0.07); and self-efficacy (
p
= 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (
p
= 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).
Conclusions
Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.
Study registration
Current Controlled Trials: ISRCTN44577970.
Funding
This project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full in
Health Services and Delivery Research
; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.
Hypokinesia and bradykinesia as movement deficits of Parkinson disease are thought to be mediated by both basal ganglia dysfunction and a loss of muscle mass and strength commensurate with aging and decreased levels of physical activity. For these reasons, we sought to utilize resistance training as a means to increase muscle force and minimize hypokinesia and bradykinesia in persons with Parkinson disease and examine the effects of exercise and medication on Body Structure and Function (muscle force production and muscle cross-sectional area), Activity (mobility), and Participation (Health Status) outcomes.
Forty-two participants were enrolled in a 12-week randomized clinical trial that compared 2 active exercise interventions: a standard care control group (Active Control) and an experimental group that underwent Resistance Exercise via Negative Eccentric Work (RENEW).
Participants in both groups improved in muscle force production and mobility as a result of exercise and medication (P < 0.02). There were no significant interaction or between-group differences and no significant changes in muscle cross-sectional area or health status were observed. Effect sizes for exercise and medication combined exceeded the effect sizes of either intervention in isolation.
Taken together, these results point to the complementary effects of exercise and medication on the Body Structure and Function and Activity outcomes but little effect on Participation outcomes. Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A92).
To determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, i.e., poor balance, reduced leg muscle strength, and freezing of gait, in people with Parkinson disease.
Two hundred thirty-one people with Parkinson disease were randomized into exercise or usual-care control groups. Exercises were practiced for 40 to 60 minutes, 3 times weekly for 6 months. Primary outcomes were fall rates and proportion of fallers during the intervention period. Secondary outcomes were physical (balance, mobility, freezing of gait, habitual physical activity), psychological (fear of falling, affect), and quality-of-life measures.
There was no significant difference between groups in the rate of falls (incidence rate ratio [IRR] = 0.73, 95% confidence interval [CI] 0.45-1.17, p = 0.18) or proportion of fallers (p = 0.45). Preplanned subgroup analysis revealed a significant interaction for disease severity (p < 0.001). In the lower disease severity subgroup, there were fewer falls in the exercise group compared with controls (IRR = 0.31, 95% CI 0.15-0.62, p < 0.001), while in the higher disease severity subgroup, there was a trend toward more falls in the exercise group (IRR = 1.61, 95% CI 0.86-3.03, p = 0.13). Postintervention, the exercise group scored significantly (p < 0.05) better than controls on the Short Physical Performance Battery, sit-to-stand, fear of falling, affect, and quality of life, after adjusting for baseline performance.
An exercise program targeting balance, leg strength, and freezing of gait did not reduce falls but improved physical and psychological health. Falls were reduced in people with milder disease but not in those with more severe Parkinson disease.
This study provides Class III evidence that for patients with Parkinson disease, a minimally supervised exercise program does not reduce fall risk. This study lacked the precision to exclude a moderate reduction or modest increase in fall risk from exercise. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).
© 2014 American Academy of Neurology.
Background:
A multidisciplinary approach is thought to be the best way to manage the motor and non-motor symptoms of Parkinson's disease, but how such care should be delivered is unknown. To address this gap in knowledge, we assessed the effectiveness of an integrated multidisciplinary approach compared with usual care.
Methods:
We recruited patients for our non-randomised controlled trial from six community hospitals in the Netherlands (two in regions where the integrated care intervention was available and four in control regions that administered usual care). Eligible patients were those with Parkinson's disease, aged 20-80 years, and without severe cognitive impairment or comorbidity. Patients in the intervention group were offered an individually tailored comprehensive assessment in an expert tertiary referral centre and subsequent referrals to a regional network of allied health professionals specialised in Parkinson's disease. Primary outcomes were activities of daily living (Academic Medical Center linear disability score [ALDS]) and quality of life (Parkinson's disease quality of life questionnaire [PDQL]) measured at 4, 6, and 8 months. Secondary outcomes included motor functioning (unified Parkinson's disease rating scale, part III [UPDRS III], at 4 months), caregiver burden (belastungsfragebogen Parkinson angehörigen-kurzversion [BELA-A-k] at 4 and 8 months), and costs (during whole study period). Primary analysis was by intention to treat and included scores over 4, 6, and 8 months, with correction for baseline score. The trial is registered at Clinicaltrials.gov, number NCT00518791.
Findings:
We recruited 301 patients (150 patients in the intervention group and 151 in the control group) between August, 2007, and December, 2009, of whom 285 completed follow-up (last follow-up was July, 2010). 101 (67%) patients in the intervention group visited the expert centre; 49 (33%) opted not to visit the expert centre. The average ALDS score from months 4, 6, and 8, with correction for baseline score, was greater in the intervention group than in the control group (difference 1·3 points, 95% CI -2·1 to 2·8; corresponding raw logit score difference 0·1, 95% CI 0·003 to 0·2) as was the average PDQL score (difference 3·0 points, 0·4 to 5·6). Secondary analysis with correction for baseline disease severity showed no differences between groups for ALDS (difference 0·9 points, 95% CI -0·6 to 2·4; corresponding raw logit score difference 0·1, -0·02 to 0·3) or PDQL (difference 1·7 points, -1·2 to 4·6). Secondary outcomes did not differ between groups (UPDRS III score difference 0·6 points, 95% CI -1·4 to 2·6; BELA-A-k score difference 0·8 points, -0·2 to 1·8; cost difference €742, -€489 to €1950).
Interpretation:
This integrated care approach offered only small benefits to patients with Parkinson's disease, and these disappeared after correction for baseline disease severity. These results suggest that different approaches are needed to achieve more substantial health benefits.
Funding:
NutsOhra Foundation, Stichting Parkinson Nederland, National Parkinson Foundation.
Parkinson's disease is one of the most common neurodegenerative disorders seen in the United States and United Kingdom. The disease is characterised by two processes-cellular degeneration and the resulting biochemical deficiency of dopamine. Although these processes are inter-related, they are approached separately in the clinical setting. Currently, no proven neuroprotective or disease modifying treatment is available for Parkinson's disease. Several agents can be used to treat the motor symptoms associated with dopamine deficiency, and it is important to choose wisely when starting treatment. Drugs can have mild, moderate, or high potency, and the patient's goals, comorbidities, and the short and long term implications of choosing a specific agent should be taken into account when selecting the appropriate agent. Non-motor symptoms, such as depression, fatigue, and disorders of sleep and wakefulness, also need to be evaluated and treated. Research is under way to deliver dopaminergic therapy more effectively, but studies aimed at slowing or stopping disease progression have not shown promise.
© BMJ Publishing Group Ltd 2014.
Backgroud
There is substantial interest in the impact of exercise on reduction of disability and rate of progression of Parkinson’s disease (PD).
Objective
The primary aim was to describe exercise habits of PD patients and factors associated with greater levels of exercise. The secondary aim was to explore whether regular exercise is associated with a slower decline of function, disease-related quality of life, and caregiver burden.
Methods
The National Parkinson’s Foundation (NPF) Registry data was used to analyze variables that correlate with levels of exercise in PD patients across disease severity. Subjects were categorized into three groups: non-exercisers (0 min/week), low exercisers (1-150 min/week), and regular exercisers (>150 min/week). Health related outcomes, disease metrics, and demographic factors associated with exercise were examined using bivariate analyses. Multiple regression models controlled for disease duration, severity, and cognitive function. An exploratory analysis was completed on the association of baseline level of exercise with health outcomes at one year follow up.
Results
4866 subjects were included in the baseline analysis and 2252 subjects who had second visits were included in the longitudinal data. Regular exercisers at baseline was associated with better QOL, mobility, and physical function, less progression of disease, less caregiver burden and less cognitive decline one year later, after controlling for demographic and disease severity variables.
Conclusions
This study provides important preliminary evidence of the beneficial effects of regular exercise in a large PD cohort. Longitudinal studies will be essential to confirm findings.
Objectives
(1) To appraise and synthesis the literature on dance interventions for individuals with Parkinson’s disease (PD), (2) to provide information regarding the frequency, intensity, duration and type of dance used in these programmes, (3) to inform the development of future studies evaluating dance interventions in this population.
Data Sources
Eight databases (MEDLINE, CINAHL, AMED, SPORTDiscus, Pubmed, Pubmed Central, Sage and ScienceDirect) were electronically searched in April 2014. The references lists from the included articles were also searched.
Study Selection
Studies retrieved during the literature search were reviewed by two reviewers independently. Suitable articles were identified by applying inclusion criteria.
Data Extraction
Data regarding participants and the frequency, intensity, duration and type of dance implemented was extracted. The effect each dance programme had on defined outcomes and the feasibility of each programme was also reviewed.
Data Synthesis
Thirteen articles were identified. The quality of studies varied and methodological limitations were evident in some. The evidence evaluated suggests two, one hour dance classes per week over ten to thirteen weeks may have beneficial effects on endurance, motor impairment and balance.
Conclusions
Dance may be helpful for some people with PD. This paper provides preliminary information to aid clinicians when implementing dance programmes for people with PD. Higher quality multi-centered studies are needed to determine the effect of other dance genres and the optimal therapy volume and intensity.
Authors post-print full text copy available: http://ulir.ul.ie/handle/10344/4401
Objective:
To determine the effects of participation in a 2-year community-based dance class on disease severity and functional mobility in people with Parkinson disease (PD).
Design:
Randomized controlled trial.
Settings/location:
Dance classes took place in a community-based location. Outcome measures were collected in a university laboratory.
Patients:
Ten individuals with PD were randomly assigned to the Argentine tango (AT) group (n=5 [4 men]; mean age±standard deviation, 69.6±6.6 years) or the control group (n=5 [4 men]; mean age±standard deviation, 66±11.0 years).
Interventions:
The AT group participated in a community-based AT class for 1 hour twice weekly for 2 years. Control group participants were given no prescribed exercise. Blinded assessments occurred at baseline and 12 and 24 months.
Outcome measures:
Movement Disorder Society-Unified Parkinson Disease Rating Scale (MDS-UPDRS) III, Mini-Balance Evaluation Systems Test (Mini-BESTest), gait velocity (forward and backward), Timed Up and Go and dual-task Timed Up and Go, Six-Minute Walk Test (6MWT), MDS-UPDRS II, MDS-UPDRS I, and Freezing of Gait Questionnaire.
Results:
There were no differences between groups at baseline. A significant group-by-time interaction (F [2,8]=17.59; p<0.0001) was noted for the MDS-UPDRS III, with the AT group having lower scores at 12 and 24 months than the controls. Significant interactions were also noted for the Mini-BESTest, MDS-UPDRS II and I, and 6MWT.
Conclusion:
This is believed to be one of the longest-duration studies to examine the effects of exercise on PD. Participation in community-based dance classes over 2 years was associated with improvements in motor and nonmotor symptom severity, performance on activities of daily living, and balance in a small group of people with PD. This is noteworthy given the progressive nature of PD and the fact that the control group declined on some outcome measures over 2 years.
Objectives:
To (1) investigate effects of aerobic walking on motor function, cognition, and quality of life in Parkinson disease (PD), and (2) compare safety, tolerability, and fitness benefits of different forms of exercise intervention: continuous/moderate intensity vs interval/alternating between low and vigorous intensity, and individual/neighborhood vs group/facility setting.
Methods:
Initial design was a 6-month, 2 × 2 randomized trial of different exercise regimens in independently ambulatory patients with PD. All arms were required to exercise 3 times per week, 45 minutes per session.
Results:
Randomization to group/facility setting was not feasible because of logistical factors. Over the first 2 years, we randomized 43 participants to continuous or interval training. Because preliminary analyses suggested higher musculoskeletal adverse events in the interval group and lack of difference between training methods in improving fitness, the next 17 participants were allocated only to continuous training. Eighty-one percent of 60 participants completed the study with a mean attendance of 83.3% (95% confidence interval: 77.5%-89.0%), exercising at 46.8% (44.0%-49.7%) of their heart rate reserve. There were no serious adverse events. Across all completers, we observed improvements in maximum oxygen consumption, gait speed, Unified Parkinson's Disease Rating Scale sections I and III scores (particularly axial functions and rigidity), fatigue, depression, quality of life (e.g., psychological outlook), and flanker task scores (p < 0.05 to p < 0.001). Increase in maximum oxygen consumption correlated with improvements on the flanker task and quality of life (p < 0.05).
Conclusions:
Our preliminary study suggests that aerobic walking in a community setting is safe, well tolerated, and improves aerobic fitness, motor function, fatigue, mood, executive control, and quality of life in mild to moderate PD.
Classification of evidence:
This study provides Class IV evidence that in patients with PD, an aerobic exercise program improves aerobic fitness, motor function, fatigue, mood, and cognition.
Background:
Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and wellbeing, thereby enhancing quality of life. Trials have shown that physiotherapy has short-term benefits in PD. However, which physiotherapy intervention is most effective remains unclear.
Objectives:
To assess the effectiveness of one physiotherapy intervention compared with a second approach in patients with PD.
Search methods:
Relevant trials were identified by electronic searches of numerous literature databases (for example MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to the end of January 2012.
Selection criteria:
Randomised controlled trials of one physiotherapy intervention versus another physiotherapy intervention in patients with PD.
Data collection and analysis:
Data were abstracted independently from each paper by two authors. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts.
Main results:
A total of 43 trials were identified with 1673 participants. All trials used small patient numbers (average trial size of 39 participants); the methods of randomisation and concealment of allocation were poor or not stated in most trials. Blinded assessors were used in just over half of the trials and only 10 stated that they used intention-to-treat analysis.A wide variety of validated and customised outcome measures were used to assess the effectiveness of physiotherapy interventions. The most frequently reported physiotherapy outcomes were gait speed and timed up and go, in 19 and 15 trials respectively. Only five of the 43 trials reported data on falls (12%). The motor subscales of the Unified Parkinson's Disease Rating Scale and Parkinson's Disease Questionnaire-39 were the most commonly reported clinician-rated disability and patient-rated quality of life outcome measures, used in 22 and 13 trials respectively. The content and delivery of the physiotherapy interventions varied widely in the trials included within this review, so no quantitative meta-analysis could be performed.
Authors' conclusions:
Considering the small number of participants examined, the methodological flaws in many of the studies, the possibility of publication bias, and the variety of interventions, formal comparison of the different physiotherapy techniques could not be performed. There is insufficient evidence to support or refute the effectiveness of one physiotherapy intervention over another in PD.This review shows that a wide range of physiotherapy interventions to treat PD have been tested . There is a need for more specific trials with improved treatment strategies to underpin the most appropriate choice of physiotherapy intervention and the outcomes measured.
LSVT-BIG is an exercise for patients with Parkinson's disease (PD) comprising of 16 1-h sessions within 4 weeks. LSVT-BIG was compared with a 2-week short protocol (AOT-SP) consisting of 10 sessions with identical exercises in 42 patients with PD. UPDRS-III-score was reduced by -6.6 in LSVT-BIG and -5.7 in AOT-SP at follow-up after 16 weeks (p < 0.001). Measures of motor performance were equally improved by LSVT-BIG and AOT-SP but high-intensity LSVT-BIG was more effective to obtain patient-perceived benefit.
Cognitive impairment and dementia associated with movement disorders represent a major management challenge and area of unmet need. This article has focused upon Parkinson's disease as an exemplar condition, but many of the roadblocks and efforts to overcome these are applicable, in a general sense, to other disorders. Short of a “penicillin moment”—a chance discovery or piece of unintended good fortune—progress is likely to be incremental. Cognitive therapies may end up being multiple and possibly multimodal, parallel with the cancer therapy field. Ultimately, benefit for one condition may extend to others as commonality in protein aggregation, synergistic pathological effects between proteins, and pathological spread emerges. © 2014 International Parkinson and Movement Disorder Society
Patients with Parkinson’s disease need long term support to manage their condition. Bastiaan Bloem and Marten Munneke describe the benefits of a model of integrated care provided by a network of specialists and suggest it has promise for other long term conditions
Advances in medical knowledge and technology, escalating healthcare costs, and rising patient expectations and involvement in their care are changing the management of chronic disease. Here, we describe how ParkinsonNet, an innovative regional network introduced in the Netherlands in 2004, has improved the quality of care and reduced the healthcare costs of patients with Parkinson’s disease. The scheme uses a select group of trained health professionals linked together through a shared online platform to which patients also have access.
Parkinson’s disease is a common and disabling neurodegenerative disorder.1 A Dutch study of 6969 community residents aged ≥55 years showed a prevalence of 1.4%,2 and an incidence ranging from 0.3/1000 in people aged 55-65 years to 4.4/1000 for those aged over 85.3 Most patients live with the disease for many years because the risk of death is increased only modestly in the absence of dementia4 but the burden of disease on patients and carers is considerable. A survey among US veterans showed that health related quality of life was substantially diminished among patients with Parkinson’s disease and that the impact of the disease outweighed that of other chronic disorders such as coronary heart disease, arthritis, diabetes, or stroke.5
Before the introduction of ParkinsonNet in the Netherlands in 2004, feedback from focus groups and online patient forums suggested that Dutch patients with Parkinson’s disease were dissatisfied with their care.6 7 They complained that treatment tended to be exclusively focused on suppression of symptoms with drugs (and sometimes stereotactic neurosurgery) and that referral to other …
In this study, we compared a cognition-specific computer-based cognitive training program with a motion-controlled computer sports game that is not cognition-specific for their ability to enhance cognitive performance in various cognitive domains in patients with Parkinson disease (PD).
Patients with PD were trained with either a computer program designed to enhance cognition (CogniPlus, 19 patients) or a computer sports game with motion-capturing controllers (Nintendo Wii, 20 patients). The effect of training in 5 cognitive domains was measured by neuropsychological testing at baseline and after training. Group differences over all variables were assessed with multivariate analysis of variance, and group differences in single variables were assessed with 95% confidence intervals of mean difference. The groups were similar regarding age, sex, and educational level.
Patients with PD who were trained with Wii for 4 weeks performed better in attention (95% confidence interval: -1.49 to -0.11) than patients trained with CogniPlus.
In our study, patients with PD derived at least the same degree of cognitive benefit from non-cognition-specific training involving movement as from cognition-specific computerized training. For patients with PD, game consoles may be a less expensive and more entertaining alternative to computer programs specifically designed for cognitive training.
This study provides Class III evidence that, in patients with PD, cognition-specific computer-based training is not superior to a motion-controlled computer game in improving cognitive performance.
The purpose of this randomized controlled study was to examine and compare the immediate and retention effects of speed-dependent treadmill training (SDTT) and rhythmic auditory-cued (RAC) overground walking on gait function and fall risk in individuals with Parkinson's disease (PD).
Twenty participants (mean age 66.1 yrs) with idiopathic PD were randomized into either SDTT (n = 10) or RAC (n = 10) progressive, interval-based locomotor training protocols. Immediate and retention training effects on gait function and fall risk were measured by comfortable and fast gait speed (CGS, FGS), 6-Minute Walk Test (6MWT), and Functional Gait Assessment (FGA).
Immediate within-group training effects revealed significant gains in CGS, 6MWT, and FGA for the RAC group, and in FGS, 6-MinuteWalk Test, and FGA for the SDTT group. Retention effects were found at 3-month follow-up for all gait measures in the RAC group, and for FGS and FGA in the SDTT group. No statistically significant differences in immediate or retention training effects on gait measures were found between groups.
Externally-cued locomotor training with progressive and interval-based speed challenges, either with RAC overground or on a treadmill, produced significant improvements in walking speed, endurance, and dynamic balance during walking.
The purpose of this single-blinded, randomized controlled study was to examine and compare the immediate and retention effects of progressive speed-dependent treadmill training (SDTT) and rhythmic auditory-cued (RAC) training on balance function, fall incidence, and quality of life (QOL) in individuals with PD.
Twenty participants (mean age 66.1 yrs) with idiopathic PD were randomized into either SDTT (n = 10) or RAC (n = 10) progressive, interval-based locomotor training for 6 weeks. Measures included the Berg Balance Scale (BBS), Rapid Step-Up Test (RST), Activities-specific Balance Confidence Scale, Parkinson's Disease Questionnaire-39 (PDQ), and the NeuroCom Sensory Organization Test (SOT), Motor Control Test, and Limits of Stability (LOS). Fall incidence was assessed prospectively post-training based on six monthly self-report fall calendars.
Significant gains in balance measures were observed post-training in BBS, RST and SOT for the RAC group and in RST, SOT and LOS for the SDTT group. Gains were retained at 3 months post-training in all measures for RAC group, but only the RST for the SDTT group. No clear trend in reduction in fall frequency was evident.
Externally-cued locomotor training paradigms with progressive speed challenges produced significant improvements in dynamic balance function in persons with PD, with stronger retention of gains in RAC group.
Neurodegenerative disorders like Parkinson's disease (PD) typically include a broad range of motor and non-motor symptoms. Disease manifestations vary considerably across individuals and, importantly, the individual needs and priorities are highly diverse among patients. It is widely felt that this multifaceted nature of PD calls for a team-oriented and personalized model of care. However, such a multispecialty approach is complex to design, and there are no evidence-based templates that describe how multispecialty care should be organized. Here we elaborate on the various challenges associated with the organization of team-based care. We illustrate this by highlighting new research evidence for two different models of multispecialty team care in PD. We also discuss several critical components of multispecialty care, including composition of the team, collaboration forms between team members, and implementation of multispecialty care within everyday healthcare settings. We close by sharing some of the lessons learned from recent clinical trials on the clinical effectiveness of multispecialty team interventions in PD. This review underscores that designing multispecialty care within the setting of a modern healthcare system is almost as complex as PD itself, and that its scientific evaluation comes with significant challenges.
There is clinical evidence that the symptoms of Parkinson's disease can be ameliorated by physical exercise, and we have been using animal models to explore the hypothesis that such exercise can also be neuroprotective. To do so we have focused on models of the dopamine deficiency associated with motor symptoms of parkinsonism, including mice treated systemically with MPTP and rats treated with 6-hydroxydopamine. Our focus on exercise derives in part from the extensive literature on the ability of exercise to increase mitochondrial respiration and antioxidant defenses, and to stimulate neuroplasticity. Beginning with constraint therapy and then employing wheel running and environmental enrichment, we have shown that increased limb use can reduce the behavioral effects of dopamine-directed neurotoxins and reduce the loss of dopamine neurons that would otherwise occur. While the mechanism of these effects is not yet known, we suspect a central role for neurotrophic factors whose expression can be stimulated by exercise and which can act on dopamine neurons to reduce their vulnerability to toxins. We believe these data, together with observations from several other laboratories, suggest that exercise, as well as neurotrophic factors, is likely to be an effective neuroprotective strategy in the treatment of Parkinson's disease.
Objective:
To determine the effects of leg muscle power training in people with Parkinson's disease.
Design:
Randomized controlled trial.
Setting:
University laboratory (outcome measures and experimental intervention), community (control intervention).
Subjects:
Community-dwelling people with Parkinson's disease.
Interventions:
Leg muscle power training using pneumatic variable resistance equipment (experimental) was compared with low intensity sham exercise (control). Both groups exercised twice weekly for 12 weeks.
Main measures:
Primary outcomes were peak power of four leg muscle groups. Secondary outcomes were measures of muscle strength, mobility, balance and falls.
Results:
Exercise adherence was high in both groups. Leg muscle power was significantly better in the experimental group than the control group in all four primary outcome measures at 12 weeks after adjusting for baseline values: leg extensors (57.9 watts, 95% confidence interval (CI) 22.0-93.7, p = 0.002); knee flexors (29.6 watts, 95% CI 7.4-51.8, p = 0.01); hip flexors (68.1 watts, 95% CI 19.6-116.5, p = 0.007); and hip abductors (37.4 watts, 95% CI 19.9-54.9, p < 0.001). The experimental group performed significantly better on tests of leg muscle strength (p < 0.001 to 0.07) and showed trends toward better performance in the Timed Up and Go (p = 0.13) and choice stepping reaction time (p = 0.11). There was a non-significant reduction in the rate of falls in the experimental group compared with the control group (incidence rate ratio 0.84, p = 0.76).
Conclusions:
This programme significantly improved muscle power in all trained muscle groups.
Parkinson's disease is a prevalent neurodegenerative disorder for which only symptomatic treatment exists. Gait and balance disturbance is common in Parkinson's disease and is a major contributor to increased disability and decreased health-related quality of life and survival. Balance and gait deficits in Parkinson's disease are notoriously difficult to treat and are not significantly helped by pharmacological or surgical treatment. The last two decades have seen a dramatic increase in the research and clinical interest in using exercise as a treatment for mobility problems in people with Parkinson's disease. With exciting advances in basic science research suggesting neurochemical and neuroplastic changes after exercise, an increasing number of high-quality studies are documenting particular aspects of mobility improving after exercise. Exercise has the potential to help both motor (gait, balance, strength) and nonmotor (depression, apathy, fatigue, constipation) aspects of Parkinson's disease as well as secondary complications of immobility (cardiovascular, osteoporosis). This perspective article focuses primarily on recent evidence on the effects of exercise in improving mobility while highlighting the importance of targeted exercise intervention for maximizing the benefits of exercise. Suggestions for exercise guidelines, adherence issues, and directions for future research are provided. © 2013 International Parkinson and Movement Disorder Society.
Parkinson’s disease (PD) is the second most common neurodegenerative disorder that affects approximately 1 % of people over the age of 60 years. Accurate diagnosis and individualized assessment of the risks and benefits of available antiparkinsonian medications as well as specific clinical features and the phase of disease should guide treatment for patients with PD. Levodopa still remains the gold standard for the treatment of motor symptoms of PD but dopamine agonists (DAs), catechol-O-methyltransferase (COMT) inhibitors and monoamine oxidase B (MAO-B) inhibitors have also been developed to provide more continuous oral delivery of dopaminergic stimulation in order to improve motor outcomes and decrease the risk of levodopa-induced motor complications. Deep-brain stimulation as well as other invasive therapies can be used for the treatment of drug-refractory levodopa-induced motor complications. Despite all of the therapeutic advances achieved within the last 20 years, PD continues to be a progressive disorder leading to severe disability caused by motor and non-motor symptoms. To date, neuroprotective interventions able to modify PD progression are not available. This review focuses on medical and invasive treatment strategies for early and advanced stages of PD as well as on the treatment of PD non-motor symptoms such as mood and behavioural disorders, cognitive and autonomic dysfunction, and sleep disorders, which can antedate PD motor symptoms for years.